Healthcare Provider Details

I. General information

NPI: 1255592283
Provider Name (Legal Business Name): RALEIGH FAMILY PRACTICE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2008
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 LAKE BOONE TRL 502
RALEIGH NC
27607-7513
US

IV. Provider business mailing address

5626 OBERLIN DR SUITE 110
SAN DIEGO CA
92121-1705
US

V. Phone/Fax

Practice location:
  • Phone: 919-875-0539
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number23998
License Number StateNC

VIII. Authorized Official

Name: KENNY HEINE
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 858-625-2990