Healthcare Provider Details

I. General information

NPI: 1184209470
Provider Name (Legal Business Name): CEDAR OAKS CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 02/01/2022
Certification Date: 02/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1748 HERITAGE CENTER DR STE 101
WAKE FOREST NC
27587-9855
US

IV. Provider business mailing address

1748 HERITAGE CENTER DR STE 101
WAKE FOREST NC
27587-9855
US

V. Phone/Fax

Practice location:
  • Phone: 919-332-8969
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CEDAR OAKS CLINIC
Title or Position: CLINIC
Credential:
Phone: 919-529-5920