Basic Information
| Provider Information | |||||||||
| NPI: | 1255574331 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAKE HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OBERLIN OUTREACH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 NEW BERN AVE | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101821 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192502944 | ||||||||
| FaxNumber: | 9192502949 | ||||||||
| Practice Location | |||||||||
| Address1: | 1012 OBERLIN RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198333111 | ||||||||
| FaxNumber: | 9192502949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2009 | ||||||||
| LastUpdateDate: | 04/20/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | MORLANDO | ||||||||
| AuthorizedOfficialFirstName: | JACQUELINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9192502939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WAKE HEALTH SERVICES, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.