Healthcare Provider Details

I. General information

NPI: 1144629833
Provider Name (Legal Business Name): NORTH CAROLINA A&T STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2014
Last Update Date: 08/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 N BENBOW RD
GREENSBORO NC
27411-0002
US

IV. Provider business mailing address

112 N BENBOW RD
GREENSBORO NC
27411-0002
US

V. Phone/Fax

Practice location:
  • Phone: 336-334-7880
  • Fax: 336-334-7154
Mailing address:
  • Phone: 336-334-7880
  • Fax: 336-334-7154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number00549
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number9900552
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number9501417
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number24834
License Number StateNC

VIII. Authorized Official

Name: BETTYE YOUNG-STEWART
Title or Position: HEALTH CENTER DIRECTOR
Credential:
Phone: 336-334-7880