=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245780303
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TARHEEL FOOT & SPECIALTY CARE, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2016
-----------------------------------------------------
Last Update Date | 07/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 BIRCH ST SUITE B
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-3297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-904-6600
-----------------------------------------------------
Fax | 910-904-1810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 BIRCH ST SUITE B
-----------------------------------------------------
City | RAEFORD
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28376-3297
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-904-6600
-----------------------------------------------------
Fax | 910-904-1810
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | HR MANAGER
-----------------------------------------------------
Name | CAROL LYNN KEELER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-929-6944
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0505X
-----------------------------------------------------
Taxonomy Name | Adult Medicine Physician
-----------------------------------------------------
License Number | 900257
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------