Healthcare Provider Details

I. General information

NPI: 1235198482
Provider Name (Legal Business Name): TALL OAKS FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 OAK RIDGE FARM RD. SUITE A
MOORESVILLE NC
28115
US

IV. Provider business mailing address

798 OAK RIDGE FARM RD. SUITE A
MOORESVILLE NC
28115
US

V. Phone/Fax

Practice location:
  • Phone: 704-658-0011
  • Fax: 704-658-0012
Mailing address:
  • Phone: 704-658-0011
  • Fax: 704-658-0012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number101555
License Number StateNC

VIII. Authorized Official

Name: MR. KEVIN B VANHOY
Title or Position: OWNER, PROVIDER
Credential: P.A.C.
Phone: 704-658-0011