Healthcare Provider Details

I. General information

NPI: 1710209234
Provider Name (Legal Business Name): SAMPSON REGIONAL PROFESSIONAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2010
Last Update Date: 08/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1004 BEAMAN ST
CLINTON NC
28328-2329
US

IV. Provider business mailing address

PO BOX 890315
CHARLOTTE NC
28289-0315
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-9113
  • Fax: 910-590-0050
Mailing address:
  • Phone: 910-592-8511
  • Fax: 910-592-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number99999
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number99999
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number99999
License Number StateNC

VIII. Authorized Official

Name: MR. HUNTER BALLTZGLIER
Title or Position: DIRECTOR
Credential:
Phone: 910-590-8755