Basic Information
| Provider Information | |||||||||
| NPI: | 1730505470 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PORT HEALTH SERVICES | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PORT HUMAN SERVICES | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4300-110 SAPPHIRE CT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2528307540 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2206 WRIGHTSVILLE AVE # A | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284032406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9102515326 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2014 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | ROUNTREE | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | REIMBURSEMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2528307540 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
No ID Information.