Healthcare Provider Details

I. General information

NPI: 1770872228
Provider Name (Legal Business Name): SCOTLAND PRIMARY CARE CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2011
Last Update Date: 12/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S MAIN ST
LAURINBURG NC
28352-4724
US

IV. Provider business mailing address

805 S MAIN ST
LAURINBURG NC
28352-4724
US

V. Phone/Fax

Practice location:
  • Phone: 910-506-4679
  • Fax: 910-506-4699
Mailing address:
  • Phone: 910-506-4679
  • Fax: 910-506-4699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number900344
License Number StateNC

VIII. Authorized Official

Name: MRS. JONNA LYNN SQUIRES
Title or Position: INSURANCE BILLING MANAGER
Credential: MPHA
Phone: 910-506-4679