Healthcare Provider Details

I. General information

NPI: 1780088971
Provider Name (Legal Business Name): SOPHIA WATTS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2014
Last Update Date: 10/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 S POPLAR ST
ELIZABETHTOWN NC
28337-9226
US

IV. Provider business mailing address

804 S POPLAR ST
ELIZABETHTOWN NC
28337-9226
US

V. Phone/Fax

Practice location:
  • Phone: 910-862-8100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number7014
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: