Healthcare Provider Details

I. General information

NPI: 1649236845
Provider Name (Legal Business Name): HEADACHE WELLNESS CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1414 YANCEYVILLE STREET FIRST FLOOR
GREENSBORO NC
27405-6930
US

IV. Provider business mailing address

1414 YANCEYVILLE STREET FIRST FLOOR
GREENSBORO NC
27405-6930
US

V. Phone/Fax

Practice location:
  • Phone: 336-574-8000
  • Fax: 336-574-8008
Mailing address:
  • Phone: 336-574-8000
  • Fax: 336-574-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number84461
License Number StateNC

VIII. Authorized Official

Name: MARSHALL C FREEMAN
Title or Position: CO OWNER
Credential: MD
Phone: 336-574-8000