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General NPI Number Information
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NPI Number | 1619276318
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Entity Type | Organization
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Legal Business Name | WAKEHEALTH MEDICAL GROUP, PA.
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Dates
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Enumeration Date | 03/21/2011
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Last Update Date | 09/04/2012
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Provider Practice Location Address
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Address Line | 13200 NEW FALLS OF NEUSE RD STE 113
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City | RALEIGH
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State | NC
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Zip | 27614-8239
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Country | US
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Telephone | 919-554-6754
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Fax | 919-554-6756
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Provider Business Mailing Address
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Address Line | 13200 NEW FALLS OF NEUSE RD STE 113
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City | RALEIGH
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State | NC
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Zip | 27614-8239
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Country | US
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Telephone | 919-554-6754
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Fax | 919-554-6756
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DEBBIE LEFFERTS
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Credential |
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Telephone | 919-554-6754
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 138957
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License Number State | NC
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