Basic Information
| Provider Information | |||||||||
| NPI: | 1770821589 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BAKERSVILLE COMMUNITY MEDICAL CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 86 N MITCHELL AVE | ||||||||
| Address2: | |||||||||
| City: | BAKERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287056502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286882104 | ||||||||
| FaxNumber: | 8286881334 | ||||||||
| Practice Location | |||||||||
| Address1: | 36 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SPRUCE PINE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287778943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8287667778 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2013 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | SHELTON | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | WAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8286882104 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BAKERSVILLE COMMUNITY MEDICAL CLINIC, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.