1780877795 NPI number — WAKE HEART AND VASCULAR ASSOCIATES P.A.

Table of content: MRS. JENNY GIBBS HOLMES LPC (NPI 1225163603)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780877795 NPI number — WAKE HEART AND VASCULAR ASSOCIATES P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WAKE HEART AND VASCULAR ASSOCIATES P.A.
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:
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:
1780877795
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 REDWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISBURG
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27549-2678
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-496-3909
Provider Business Mailing Address Fax Number:
919-496-5032

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 REDWOOD LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOUISBURG
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27549-2678
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-496-3909
Provider Business Practice Location Address Fax Number:
919-496-5032
Provider Enumeration Date:
08/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DARKES
Authorized Official First Name:
DEE
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
919-420-1342

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 230473 . This is a "MEDICARE GROUP" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 02029 . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7902029 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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