Healthcare Provider Details

I. General information

NPI: 1548685365
Provider Name (Legal Business Name): ALICE KORNEGAY LMBT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ALICE FASSNACHT LMBT

II. Dates (important events)

Enumeration Date: 03/03/2014
Last Update Date: 03/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2837B DAISY LN N
WILSON NC
27896-6942
US

IV. Provider business mailing address

412 S WALNUT ST
PRINCETON NC
27569-9301
US

V. Phone/Fax

Practice location:
  • Phone: 252-206-1900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number7344
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code173C00000X
TaxonomyReflexologist
License Number7344
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: