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1053103796 NPI number — BEACH PRIMARY CARE AND WELLNESS PLLC

NPI Number: 1053103796
Health Care Provider/Practitioner: BEACH PRIMARY CARE AND WELLNESS PLLC

Information about “1053103796” NPI (BEACH PRIMARY CARE AND WELLNESS PLLC) exists in 1053103796 in HTML format HTML  |  1053103796 in plain Text format TXT  |  1053103796 in PDF (Portable Document Format) PDF  |  1053103796 in an XML format XML  formats.

NPI Number : 1053103796 – JSON Data Format

                
{
  "Npi": {
    "NPI": "1053103796",
    "EntityType": "Organization",
    "ReplacementNPI": null,
    "EIN": null,
    "IsSoleProprietor": null,
    "IsOrgSubpart": "N",
    "ParentOrgLBN": null,
    "ParentOrgTIN": null,
    "OrgName": "BEACH PRIMARY CARE AND WELLNESS PLLC",
    "LastName": null,
    "FirstName": null,
    "MiddleName": null,
    "NamePrefix": null,
    "NameSuffix": null,
    "Credential": null,
    "OtherOrgName": null,
    "OtherOrgNameTypeCode": null,
    "OtherLastName": null,
    "OtherFirstName": null,
    "OtherMiddleName": null,
    "OtherNamePrefix": null,
    "OtherNameSuffix": null,
    "OtherCredential": null,
    "OtherLastNameTypeCode": null,
    "FirstLineMailingAddress": "1920 STONE BALLAST WAY SW",
    "SecondLineMailingAddress": null,
    "MailingAddressCityName": "OCEAN ISLE BEACH",
    "MailingAddressStateName": "NC",
    "MailingAddressPostalCode": "28469-6537",
    "MailingAddressCountryCode": "US",
    "MailingAddressTelephoneNumber": "910-995-7022",
    "MailingAddressFaxNumber": null,
    "FirstLinePracticeLocationAddress": "863 OCEAN HWY W",
    "SecondLinePracticeLocationAddress": null,
    "PracticeLocationAddressCityName": "SUPPLY",
    "PracticeLocationAddressStateName": "NC",
    "PracticeLocationAddressPostalCode": "28462-4059",
    "PracticeLocationAddressCountryCode": "US",
    "PracticeLocationAddressTelephoneNumber": "910-995-7022",
    "PracticeLocationAddressFaxNumber": null,
    "EnumerationDate": "05/19/2025",
    "LastUpdateDate": "07/16/2025",
    "NPIDeactivationReasonCode": null,
    "NPIDeactivationReason": null,
    "NPIDeactivationDate": null,
    "NPIReactivationDate": null,
    "GenderCode": null,
    "Gender": null,
    "AuthorizedOfficialLastName": "CRICHTON",
    "AuthorizedOfficialFirstName": "MARY",
    "AuthorizedOfficialMiddleName": "RUDD",
    "AuthorizedOfficialTitle": "FAMILY NURSE PRACTITIONER",
    "AuthorizedOfficialNamePrefix": "DR.",
    "AuthorizedOfficialNameSuffix": null,
    "AuthorizedOfficialCredential": "DNP",
    "AuthorizedOfficialTelephoneNumber": "910-995-7022",
    "Taxonomies": {
      "Taxonomy": [
        {
          "TaxonomyCode": "261QP2300X",
          "TaxonomyName": "Primary Care Clinic/Center",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "N"
        },
        {
          "TaxonomyCode": "207Q00000X",
          "TaxonomyName": "Family Medicine Physician",
          "LicenseNumber": null,
          "LicenseNumberStateCode": null,
          "PrimaryTaxonomySwitch": "Y"
        }
      ]
    },
    "HealthcareProviderTaxonomyGroups": {
      "HealthcareProviderTaxonomyGroup": {
        "HealthcareProviderTaxonomyGroupName": "193200000X MULTI-SPECIALTY GROUP",
        "HealthcareProviderTaxonomyGroupDescription": "Multi-Specialty Group - A business group of one or more individual practitioners, who practice with different areas of specialization."
      }
    }
  }
}
                
            

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