1710038732 NPI number — LONGLEAF NEURO MEDICAL TREATMENT CENTER

Table of content: (NPI 1710038732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710038732 NPI number — LONGLEAF NEURO MEDICAL TREATMENT CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LONGLEAF NEURO MEDICAL TREATMENT CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710038732
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4761 WARD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILSON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27893-4359
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-399-2109
Provider Business Mailing Address Fax Number:
252-399-2136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4761 WARD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27893-4359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-399-2109
Provider Business Practice Location Address Fax Number:
252-399-2136
Provider Enumeration Date:
01/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BURKES
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
Authorized Official Title or Position:
DIVISION DIRECTOR
Authorized Official Telephone Number:
919-855-4700

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 02460 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3406177 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3405192 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2066141 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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