Basic Information
| Provider Information | |||||||||
| NPI: | 1124450226 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PIEDMONT HEALTH SERVICES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SILER CITY CHC DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 224 S 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | SILER CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273442779 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 224 S 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | SILER CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 273442779 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199338494 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2013 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TOOMEY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9199338494 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 344517D | 05 | NC | MEDICAID |