Healthcare Provider Details

I. General information

NPI: 1801643788
Provider Name (Legal Business Name): MR. JOHN JOSEPH FRUTCHEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E PENNSYLVANIA AVE STE 15
SOUTHERN PINES NC
28387-6100
US

IV. Provider business mailing address

121 CARTHAGE ST
CAMERON NC
28326-9789
US

V. Phone/Fax

Practice location:
  • Phone: 727-244-0146
  • Fax:
Mailing address:
  • Phone: 727-244-0146
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13453
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: