Healthcare Provider Details

I. General information

NPI: 1063653178
Provider Name (Legal Business Name): EASTOVER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2009
Last Update Date: 03/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 DUNN RD SUITE 103
EASTOVER NC
28312-8794
US

IV. Provider business mailing address

400 LIBERTY HILL RD
LUMBERTON NC
28358-2446
US

V. Phone/Fax

Practice location:
  • Phone: 910-738-8060
  • Fax: 910-671-3600
Mailing address:
  • Phone: 910-738-8060
  • Fax: 910-671-3600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ROSE C DUCKWORTH
Title or Position: COMPLIANCE OFFICER
Credential: CPC, CMIS, CMOM
Phone: 910-738-8060