Basic Information
| Provider Information | |||||||||
| NPI: | 1609151513 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VETERAN AFFAIRS MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2300 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283013856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2300 RAMSEY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283013856 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104882120 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 10/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | WILKERSON | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | REBECCA | ||||||||
| AuthorizedOfficialTitleorPosition: | DIETITIAN | ||||||||
| AuthorizedOfficialTelephone: | 9104882120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DEPARTMENT OF VETERAN AFFAIRS | ||||||||
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| AuthorizedOfficialCredential: | MS, RD, LD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | L003818 | NC | Y | Hospitals | General Acute Care Hospital |
No ID Information.