1780760777 NPI number — CAPE LOOKOUT MEDICAL SERV

Table of content: (NPI 1780760777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780760777 NPI number — CAPE LOOKOUT MEDICAL SERV

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPE LOOKOUT MEDICAL SERV
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:
1780760777
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106D PROFESSIONAL PARK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAUFORT
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28516-2464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-728-5003
Provider Business Mailing Address Fax Number:
252-728-3841

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106D PROFESSIONAL PARK DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BEAUFORT
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28516-2418
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-728-5003
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KUERS
Authorized Official First Name:
PETER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
252-728-5003

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 015FE . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 89015FE , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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