Healthcare Provider Details

I. General information

NPI: 1902413875
Provider Name (Legal Business Name): YMCA OF SOUTHEASTERN NC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2020
Last Update Date: 09/25/2020
Certification Date: 09/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 MARKET STREET
WILMINGTON NC
28403
US

IV. Provider business mailing address

PO BOX 3467
WILMINGTON NC
28406
US

V. Phone/Fax

Practice location:
  • Phone: 910-251-8196
  • Fax: 844-854-4659
Mailing address:
  • Phone: 910-251-9622
  • Fax: 844-854-4659

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name: MRS. BRIDGET MICHELLE CARROLL
Title or Position: COORDINATOR OF COMMUNITY HEALTH PRO
Credential:
Phone: 910-251-9622