Healthcare Provider Details

I. General information

NPI: 1780262402
Provider Name (Legal Business Name): AHAVA HEALTHCARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2021
Last Update Date: 04/01/2021
Certification Date: 03/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 OAK ISLAND DRIVE
CARY NC
27513
US

IV. Provider business mailing address

200 OAK ISLAND DRIVE
CARY NC
27513
US

V. Phone/Fax

Practice location:
  • Phone: 919-667-4643
  • Fax:
Mailing address:
  • Phone: 919-667-4643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MELANIE MINTZER
Title or Position: CEO
Credential: MD
Phone: 919-667-4649