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General NPI Number Information
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NPI Number | 1376854083
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Entity Type | Organization
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Legal Business Name | ADVANCE FAMILY AND SPORTS MEDICINE CENTER, PLLC
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Dates
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Enumeration Date | 06/28/2010
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Last Update Date | 11/05/2010
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Provider Practice Location Address
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Address Line | 169 YADKIN VALLEY RD SUITE 101
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City | ADVANCE
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State | NC
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Zip | 27006-8786
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Country | US
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Telephone | 336-940-2659
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Fax |
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Provider Business Mailing Address
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Address Line | 169 YADKIN VALLEY RD SUITE 101
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City | ADVANCE
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State | NC
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Zip | 27006-8786
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Country | US
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Telephone | 336-940-2659
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Fax |
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Authorized Official
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Title or Position | OWNER/CEO
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Name | DR. WALTER EZEIGBO
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Credential | MD
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Telephone | 336-940-2659
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QS0010X
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Taxonomy Name | Sports Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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