Healthcare Provider Details

I. General information

NPI: 1699828475
Provider Name (Legal Business Name): ASHLEYBROOK CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 ASHLEYBROOK LANE
WINSTON SALEM NC
27103-2918
US

IV. Provider business mailing address

1321 ASHLEYBROOK LANE
WINSTON SALEM NC
27103-2918
US

V. Phone/Fax

Practice location:
  • Phone: 336-659-9045
  • Fax: 336-659-7866
Mailing address:
  • Phone: 336-659-9045
  • Fax: 336-659-7866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number28930
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number28930
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number28930
License Number StateNC

VIII. Authorized Official

Name: DR. THAI T PHAN
Title or Position: PRESIDENT
Credential: MD
Phone: 336-659-9045