Healthcare Provider Details

I. General information

NPI: 1841460755
Provider Name (Legal Business Name): WILMINGTON HEALTH ACCESS FOR TEENS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2008
Last Update Date: 10/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4005 OLEANDER DR
WILMINGTON NC
28403-6816
US

IV. Provider business mailing address

4005 OLEANDER DR
WILMINGTON NC
28403-6816
US

V. Phone/Fax

Practice location:
  • Phone: 910-790-9949
  • Fax: 910-790-9455
Mailing address:
  • Phone: 910-790-9949
  • Fax: 910-790-9455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA G VAN DE BOVENKAMP
Title or Position: DIRECTOR OF ADMINISTRATION
Credential: CMA (AAMA)
Phone: 910-790-9949