Healthcare Provider Details

I. General information

NPI: 1104083500
Provider Name (Legal Business Name): HARRIS FAMILY PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2008
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 EAST LIVERMORE DRIVE
PEMBROKE NC
28372-7271
US

IV. Provider business mailing address

201 EAST LIVERMORE DRIVE
PEMBROKE NC
28372-7271
US

V. Phone/Fax

Practice location:
  • Phone: 910-272-6422
  • Fax:
Mailing address:
  • Phone: 910-272-6422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9300142
License Number StateNC

VIII. Authorized Official

Name: DR. GLENN R. HARRIS
Title or Position: PRESIDENT
Credential: MD
Phone: 910-272-6422