Healthcare Provider Details

I. General information

NPI: 1255565313
Provider Name (Legal Business Name): GRANVILLE HEALTH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2009
Last Update Date: 10/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DURHAM STREET
STOVALL NC
27582
US

IV. Provider business mailing address

PO BOX 986
OXFORD NC
27565-0986
US

V. Phone/Fax

Practice location:
  • Phone: 919-690-8880
  • Fax: 919-690-8882
Mailing address:
  • Phone: 919-690-8880
  • Fax: 919-690-8882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GEORGEEN ERTISCHEK
Title or Position: ADM DIRECTOR
Credential:
Phone: 919-690-3280