Healthcare Provider Details

I. General information

NPI: 1629308572
Provider Name (Legal Business Name): ASSOCIATION OF GOODFELLOWS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2009
Last Update Date: 12/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 EBONY RD
LITTLETON NC
28590
US

IV. Provider business mailing address

PO BOX 506
AULANDER NC
27805
US

V. Phone/Fax

Practice location:
  • Phone: 252-586-4867
  • Fax: 252-586-4867
Mailing address:
  • Phone: 252-377-7081
  • Fax: 252-565-5008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberFCL093010
License Number StateNC

VIII. Authorized Official

Name: MR. ALPHONSO CHERRY
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 252-377-7081