Basic Information
| Provider Information | |||||||||
| NPI: | 1093177404 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HEREDITARY CARE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HEREDITARY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10941 RAVEN RIDGE RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276146487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192562526 | ||||||||
| FaxNumber: | 9198477471 | ||||||||
| Practice Location | |||||||||
| Address1: | 10941 RAVEN RIDGE RD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276146487 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192562526 | ||||||||
| FaxNumber: | 9198477471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 03/24/2016 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBERTS | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9198477475 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GYNECOLOGY & LAPAROSCOPIC SURGEONS, PC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 170300000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Genetic Counselor, MS | 207VG0400X | 9701567 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 261QG0250X | Y | Ambulatory Health Care Facilities | Clinic/Center | Genetics |
No ID Information.