Basic Information
| Provider Information | |||||||||
| NPI: | 1164842670 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PURA CLINIC FAMILY MEDICINE PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4860 | ||||||||
| Address2: | |||||||||
| City: | MURRELLS INLET | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295762698 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436512624 | ||||||||
| FaxNumber: | 8433574940 | ||||||||
| Practice Location | |||||||||
| Address1: | 124 BAYWOOD RD | ||||||||
| Address2: | SUITE 111 | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283128733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108295108 | ||||||||
| FaxNumber: | 9108295107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2014 | ||||||||
| LastUpdateDate: | 04/23/2014 | ||||||||
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| AuthorizedOfficialLastName: | SHAKIR | ||||||||
| AuthorizedOfficialFirstName: | MOHAMAD | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9108295108 | ||||||||
| 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 | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.