1861844763 NPI number — FAMILY AND PEDIATRIC CARE CLINIC LLC

Table of content: (NPI 1861844763)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861844763 NPI number — FAMILY AND PEDIATRIC CARE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY AND PEDIATRIC CARE CLINIC LLC
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:
1861844763
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 681
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SYLVA
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28779-0681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-339-7253
Provider Business Mailing Address Fax Number:
828-586-8209

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19067 ALBERTA ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ONEIDA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37841-6002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-569-2754
Provider Business Practice Location Address Fax Number:
423-569-2756
Provider Enumeration Date:
07/05/2016

Additional Information

Authorized Official

Authorized Official Last Name:
WEST
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
423-569-2754

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  0000020552 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363LF0000X , with the licence number: 0000016521 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 6080615 . This is a "BCBS TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: Q025132 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 103G741696 . This is a "TN MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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