=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558328781
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TABLE ROCK FAMILY MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 LINVILLE STREET
-----------------------------------------------------
City | GLEN ALPINE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-584-2481
-----------------------------------------------------
Fax | 828-584-8371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 837
-----------------------------------------------------
City | GLEN ALPINE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28628-0837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-584-2481
-----------------------------------------------------
Fax | 828-584-8371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | LAURA B JUSTICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-584-7258
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 90044
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------