Healthcare Provider Details

I. General information

NPI: 1487223814
Provider Name (Legal Business Name): ORTHONC ASC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11221 GALLERIA AVE STE 105
RALEIGH NC
27614-8137
US

IV. Provider business mailing address

PO BOX 1107
WAKE FOREST NC
27588-1107
US

V. Phone/Fax

Practice location:
  • Phone: 919-562-9410
  • Fax:
Mailing address:
  • Phone: 919-562-9410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. LISA JOHNSON
Title or Position: DIRECTOR OF CLINICAL OPERATIONS
Credential:
Phone: 919-562-9410