1740305101 NPI number — GEORGE DAVID EDENFIELD SR. PAC

Table of content: GEORGE DAVID EDENFIELD SR. PAC (NPI 1740305101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740305101 NPI number — GEORGE DAVID EDENFIELD SR. PAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDENFIELD
Provider First Name:
GEORGE
Provider Middle Name:
DAVID
Provider Name Prefix Text:
Provider Name Suffix Text:
SR.
Provider Credential Text:
PAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1740305101
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/14/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1701 WESTCHESTER DR
Provider Second Line Business Mailing Address:
STE 850
Provider Business Mailing Address City Name:
HIGH POINT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27262-7008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-802-2400
Provider Business Mailing Address Fax Number:
336-802-2534

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4431 US HIGHWAY 220 N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUMMERFIELD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27358-9411
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-643-7711
Provider Business Practice Location Address Fax Number:
336-643-3047
Provider Enumeration Date:
03/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  101537 , 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)





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