Healthcare Provider Details

I. General information

NPI: 1164005385
Provider Name (Legal Business Name): AGAPE ORTHOTICS OF NC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 11/20/2024
Certification Date: 11/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 VALLEYGATE DR STE 101A
FAYETTEVILLE NC
28304-3666
US

IV. Provider business mailing address

PO BOX 58296
FAYETTEVILLE NC
28305-8296
US

V. Phone/Fax

Practice location:
  • Phone: 910-574-9804
  • Fax:
Mailing address:
  • Phone: 910-574-9804
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code222Z00000X
TaxonomyOrthotist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State

VIII. Authorized Official

Name: CIPRIAN PUFULETE
Title or Position: MANAGER
Credential: CPED
Phone: 910-574-9804