Healthcare Provider Details

I. General information

NPI: 1346353869
Provider Name (Legal Business Name): HOLLY SPRINGS FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2006
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 ARARAT LONG HILL RD
PILOT MOUNTAIN NC
27041-8113
US

IV. Provider business mailing address

104 ARARAT LONG HILL RD
PILOT MOUNTAIN NC
27041-8113
US

V. Phone/Fax

Practice location:
  • Phone: 336-786-7966
  • Fax: 336-786-1601
Mailing address:
  • Phone: 336-786-7966
  • Fax: 336-786-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RANDALL S KEITH
Title or Position: MEDICAL DOCTOR
Credential: MD
Phone: 336-786-7966