1841697422 NPI number — CORNELIA NIXON DAVIS, INC.

Table of content: (NPI 1841697422)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841697422 NPI number — CORNELIA NIXON DAVIS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORNELIA NIXON DAVIS, INC.
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:
1841697422
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1011 PORTERS NECK RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28411-9196
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-319-2111
Provider Business Mailing Address Fax Number:
910-686-7592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
83 CAVALIER DR.
Provider Second Line Business Practice Location Address:
200
Provider Business Practice Location Address City Name:
WILMINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28405-4444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-319-2111
Provider Business Practice Location Address Fax Number:
910-686-7592
Provider Enumeration Date:
11/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
LONG
Authorized Official First Name:
CHARLES
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
EXECUTIVE DIRECTOR (CEO)
Authorized Official Telephone Number:
910-686-7195

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  NH0645 , 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: 3405568 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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