Healthcare Provider Details

I. General information

NPI: 1073749131
Provider Name (Legal Business Name): SAMPSON REGIONAL PROFESSIONAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2009
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 BEAMAN ST
CLINTON NC
28328-2602
US

IV. Provider business mailing address

PO BOX 890315
CHARLOTTE NC
28289-0315
US

V. Phone/Fax

Practice location:
  • Phone: 910-596-4262
  • Fax: 910-592-5461
Mailing address:
  • Phone: 910-592-8511
  • Fax: 910-592-5461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number99999
License Number StateNC

VIII. Authorized Official

Name: MR. GERALD HEINZMAN
Title or Position: VP/CHIEF FINANCIAL OFFICER
Credential:
Phone: 910-592-8511