Healthcare Provider Details

I. General information

NPI: 1528139987
Provider Name (Legal Business Name): CALABASH PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/10/2006
Last Update Date: 06/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10195 BEACH DR SW # 5
CALABASH NC
28467-2701
US

IV. Provider business mailing address

10195 BEACH DR SW # 5
CALABASH NC
28467-2701
US

V. Phone/Fax

Practice location:
  • Phone: 910-575-6538
  • Fax: 910-575-6541
Mailing address:
  • Phone: 910-575-6538
  • Fax: 910-575-6541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27938
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number27331
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number201575
License Number StateNC

VIII. Authorized Official

Name: CATHY SELLERS SR.
Title or Position: OWNER
Credential: NURSE PRACTICIONER
Phone: 910-575-6538