Basic Information
| Provider Information | |||||||||
| NPI: | 1417234683 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WILMINGTON HEALTH PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1202 MEDICAL CENTER DR | ||||||||
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| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9102518824 | ||||||||
| Practice Location | |||||||||
| Address1: | 2421 SILVER STREAM LN | ||||||||
| Address2: | ATTEN: CREDENTIALING | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2011 | ||||||||
| LastUpdateDate: | 01/12/2012 | ||||||||
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| AuthorizedOfficialLastName: | CHACE | ||||||||
| AuthorizedOfficialFirstName: | CHAISTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9103413300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 3404218 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 3404218 | 05 | NC | MEDICAID |