Healthcare Provider Details

I. General information

NPI: 1518625607
Provider Name (Legal Business Name): LIVING THE BREAMEDICAL - EDENTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 W QUEEN ST
EDENTON NC
27932-1733
US

IV. Provider business mailing address

PO BOX 808
STOKESDALE NC
27357-0808
US

V. Phone/Fax

Practice location:
  • Phone: 252-702-0267
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JAMIE MARTIN ATKINS
Title or Position: REGIONAL MANAGER
Credential:
Phone: 336-501-1095