Basic Information
| Provider Information | |||||||||
| NPI: | 1952799892 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAMILY WELLNESS CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2076 NC HIGHWAY 42 W STE 230 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195535711 | ||||||||
| FaxNumber: | 9195535712 | ||||||||
| Practice Location | |||||||||
| Address1: | 2076 NC HIGHWAY 42 W STE 230 | ||||||||
| Address2: | |||||||||
| City: | CLAYTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275205303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195535711 | ||||||||
| FaxNumber: | 9195535712 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2014 | ||||||||
| LastUpdateDate: | 12/30/2014 | ||||||||
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| AuthorizedOfficialLastName: | TANK | ||||||||
| AuthorizedOfficialFirstName: | BHAVNA | ||||||||
| AuthorizedOfficialMiddleName: | VAIDYA | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9195535711 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | 200400430 | NC | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | CA891372V | 05 | NC | MEDICAID |