=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871585786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HIGHLAND-VALLEY PEDIATRIC CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2005
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1219 WALTER REED RD
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28304-4437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-609-4946
-----------------------------------------------------
Fax | 910-609-5407
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 41209
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28309-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-609-6448
-----------------------------------------------------
Fax | 910-609-7040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. RICHARD H PARKS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-609-6700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | H0213
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------