=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477375954
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIHALO PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2024
-----------------------------------------------------
Last Update Date | 10/28/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1271 OLD US 1 HWY
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387-6308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-423-3949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 340 FOX BOX RD
-----------------------------------------------------
City | VASS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28394-3301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 607-423-3949
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. KENNETH JOHNSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 607-423-3949
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------