Healthcare Provider Details

I. General information

NPI: 1720116684
Provider Name (Legal Business Name): FAYETTEVILLEVAMC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 RAMSEY ST
FAYETTEVILLE NC
28301-3856
US

IV. Provider business mailing address

9 PULLEY PL
DURHAM NC
27707-2436
US

V. Phone/Fax

Practice location:
  • Phone: 910-488-2120
  • Fax:
Mailing address:
  • Phone: 919-493-7654
  • Fax: 919-489-6588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. SUBARRO PEMMARAJU
Title or Position: CHIEF OF LTC
Credential: MD
Phone: 910-488-2120