1912190406 NPI number — CYNTHIA WELLS MCLEMORE

Table of content: (NPI 1912190406)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912190406 NPI number — CYNTHIA WELLS MCLEMORE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CYNTHIA WELLS MCLEMORE
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:
1912190406
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4534
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28374-4534
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-995-7941
Provider Business Mailing Address Fax Number:
866-206-0778

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
61 MCKOY STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOFFMAN
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28347-9735
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-995-7941
Provider Business Practice Location Address Fax Number:
866-206-0778
Provider Enumeration Date:
08/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MCLEMORE
Authorized Official First Name:
CYNTHIA
Authorized Official Middle Name:
WELLS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
910-995-7941

Provider Taxonomy Codes

  • Taxonomy code: 302R00000X , with the licence number:  26678 , 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: 5909200 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8950341 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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