Basic Information
Provider Information
NPI: 1598911885
EntityType: 2
ReplacementNPI:  
OrganizationName: BOICE-WILLIS CLINIC, PA
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Mailing Information
Address1: 901 N WINSTEAD AVE
Address2:  
City: ROCKY MOUNT
State: NC
PostalCode: 278048467
CountryCode: US
TelephoneNumber: 2529370200
FaxNumber: 2524430096
Practice Location
Address1: 901 N WINSTEAD AVE
Address2:  
City: ROCKY MOUNT
State: NC
PostalCode: 278048467
CountryCode: US
TelephoneNumber: 2529370200
FaxNumber: 2529372903
Other Information
ProviderEnumerationDate: 08/18/2008
LastUpdateDate: 02/17/2022
NPIDeactivationReasonCode:  
NPIDeactivationDate: 01/07/2022
NPIReactivationDate: 02/17/2022
ProviderGenderCode:  
AuthorizedOfficialLastName: FAZIO
AuthorizedOfficialFirstName: GARY
AuthorizedOfficialMiddleName: F
AuthorizedOfficialTitleorPosition: CHIEF EXECUTIVE OFFICER
AuthorizedOfficialTelephone: 2529370200
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
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NPICertificationDate: 02/17/2022

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
291U00000X38821NCY LaboratoriesClinical Medical Laboratory 

ID Information
IDTypeStateIssuerDescription
890046505NC MEDICAID


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