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General NPI Number Information
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NPI Number | 1225645542
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Entity Type | Organization
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Legal Business Name | ISLAND TIME MEDICAL AND WELLNESS, PLLC
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Dates
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Enumeration Date | 09/30/2020
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Last Update Date | 09/30/2020
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Provider Practice Location Address
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Address Line | 39 DOWITCHER TRL
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City | BALD HEAD ISLAND
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State | NC
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Zip | 28461
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Country | US
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Telephone | 336-848-8250
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3422
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City | BALD HEAD ISLAND
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State | NC
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Zip | 28461-7004
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Country | US
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Telephone | 336-848-8250
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Fax |
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Authorized Official
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Title or Position | NP / OWNER
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Name | LOU A EARNHARDT
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Credential | AGPCNP-BC
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Telephone | 336-848-8250
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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