Healthcare Provider Details

I. General information

NPI: 1760702682
Provider Name (Legal Business Name): MISSION MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2010
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

490 HOSPITAL DR 2ND FLOOR
CLYDE NC
28721-8026
US

IV. Provider business mailing address

PO BOX 602373
CHARLOTTE NC
28260-2373
US

V. Phone/Fax

Practice location:
  • Phone: 828-456-9006
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JILL HOGGARD GREEN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 828-213-9637