Basic Information
Provider Information | |||||||||
NPI: | 1962509372 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PINEHURST MEDICAL CLINIC, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PMC REFERENCE LAB | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 205 PAGE RD | ||||||||
Address2: |   | ||||||||
City: | PINEHURST | ||||||||
State: | NC | ||||||||
PostalCode: | 283748798 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9102955511 | ||||||||
FaxNumber: | 9102353443 | ||||||||
Practice Location | |||||||||
Address1: | 200 PAVILION WAY | ||||||||
Address2: |   | ||||||||
City: | SOUTHERN PINES | ||||||||
State: | NC | ||||||||
PostalCode: | 283874561 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106399088 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/20/2006 | ||||||||
LastUpdateDate: | 09/13/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | ENFINGER | ||||||||
AuthorizedOfficialFirstName: | BRANDON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9102353004 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/16/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 39578 | NC | Y |   | Laboratories | Clinical Medical Laboratory |   |
ID Information
ID | Type | State | Issuer | Description | 7001306 | 05 | NC |   | MEDICAID | 690003763 | 01 |   | PALMETTO GBA (R/R MCR) | OTHER | FH6600055 | 01 |   | FIRSTCAROLINACARE | OTHER | 02418 | 01 |   | BC/BS NC | OTHER |