Healthcare Provider Details

I. General information

NPI: 1306967880
Provider Name (Legal Business Name): HEARTWORKS CHILDRENS MEDICAL HOME MISSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MAIN STREET
BAYBORO NC
28515
US

IV. Provider business mailing address

PO BOX 365
BAYBORO NC
28515-0365
US

V. Phone/Fax

Practice location:
  • Phone: 252-745-4510
  • Fax: 252-745-4511
Mailing address:
  • Phone: 252-745-4510
  • Fax: 252-745-4511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: LINDSEY WILLIS
Title or Position: BILLING MANAGER
Credential:
Phone: 252-745-4510