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General NPI Number Information
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NPI Number | 1477099471
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Entity Type | Organization
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Legal Business Name | PRIVATE DIAGNOSITC CLINIC
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Dates
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Enumeration Date | 01/13/2017
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Last Update Date | 09/12/2023
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Provider Practice Location Address
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Address Line | 10211 ALM ST SUITE 200
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City | RALEIGH
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State | NC
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Zip | 27617-8221
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Country | US
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Telephone | 919-307-0301
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Fax | 919-307-0323
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Provider Business Mailing Address
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Address Line | PO BOX 110566
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City | DURHAM
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State | NC
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Zip | 27709-5566
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Country | US
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Telephone | 919-620-4855
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Fax | 919-307-0323
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Authorized Official
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Title or Position | EXECUTIVE VICE DEAN ADMINISTRATION
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Name | JAMES SCOTT GIBSON
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Credential |
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Telephone | 919-684-3945
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | 561029437
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License Number State | NC
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