=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699881615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SCOTS PINE CLINIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/22/2006
-----------------------------------------------------
Last Update Date | 07/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 515 E LAUCHWOOD DR
-----------------------------------------------------
City | LAURINBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28352-5502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-276-1775
-----------------------------------------------------
Fax | 910-276-1773
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1205 515 E. LAUCHWOOD DR
-----------------------------------------------------
City | LAURINBURG
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28353-1205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-276-1775
-----------------------------------------------------
Fax | 910-276-1773
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER / MANAGER
-----------------------------------------------------
Name | DR. CLARK BERYL HANMER
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 910-276-1775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 124239
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------