Basic Information
Provider Information | |||||||||
NPI: | 1902855786 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | YANCEY COUNTY PRIMARY CARE CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TOE RIVER HEALTH DISTRICT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 202 MEDICAL CAMPUS DR. | ||||||||
Address2: |   | ||||||||
City: | BURNSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 28714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286826118 | ||||||||
FaxNumber: | 8286826262 | ||||||||
Practice Location | |||||||||
Address1: | 202 MEDICAL CAMPUS DR. | ||||||||
Address2: |   | ||||||||
City: | BURNSVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 28714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8286826118 | ||||||||
FaxNumber: | 8286826262 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/09/2006 | ||||||||
LastUpdateDate: | 11/27/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KINNANE | ||||||||
AuthorizedOfficialFirstName: | LYNDA | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | INTERIM HEALTH DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8287659081 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   | NC | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 343828A | 05 | NC |   | MEDICAID | 343828C | 05 | NC |   | MEDICAID | 3404300 | 05 | NC |   | MEDICAID | 3404484 | 05 | NC |   | MEDICAID |