Healthcare Provider Details

I. General information

NPI: 1780069807
Provider Name (Legal Business Name): EQUIJOURNEY INTERNATIONAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2015
Last Update Date: 07/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1160 AIKEN RD
VASS NC
28394-9679
US

IV. Provider business mailing address

1160 AIKEN RD
VASS NC
28394-9679
US

V. Phone/Fax

Practice location:
  • Phone: 910-398-0999
  • Fax:
Mailing address:
  • Phone: 910-398-0999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number122888
License Number StateNC

VIII. Authorized Official

Name: TERESA M GRAHAM
Title or Position: OWNER
Credential: R.N, B.S.
Phone: 910-398-0999