Healthcare Provider Details

I. General information

NPI: 1538538509
Provider Name (Legal Business Name): MUSTARD SEED COMMUNITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2015
Last Update Date: 04/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238 S ENGLISH ST
GREENSBORO NC
27401-3648
US

IV. Provider business mailing address

238 S ENGLISH ST
GREENSBORO NC
27401-3648
US

V. Phone/Fax

Practice location:
  • Phone: 336-763-0814
  • Fax: 336-763-0815
Mailing address:
  • Phone: 336-763-0814
  • Fax: 336-763-8709

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200001414
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200001414
License Number StateNC

VIII. Authorized Official

Name: ELIZABETH MARIE MULBERRY
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 336-314-5489