Basic Information
| Provider Information | |||||||||
| NPI: | 1619243300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DLP TWIN COUNTY PHYSICIAN PRACTICES LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PEDIATRIC FAMILY CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 106 DOCTORS PARK | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762368166 | ||||||||
| FaxNumber: | 2762365247 | ||||||||
| Practice Location | |||||||||
| Address1: | 106 DOCTORS PARK | ||||||||
| Address2: | |||||||||
| City: | GALAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243332276 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2762368166 | ||||||||
| FaxNumber: | 2762365247 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2012 | ||||||||
| LastUpdateDate: | 05/03/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JUDY | ||||||||
| AuthorizedOfficialFirstName: | JESS | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6153728500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | N | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Licensed Practical Nurse | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.