=====================================================
General NPI Number Information
=====================================================
NPI Number | 1992010094
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WACCAMAW PRIMARY CARE INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2010
-----------------------------------------------------
Last Update Date | 08/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 619 JEFFERSON ST
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-3707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-642-2230
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 790
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-0790
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-641-0400
-----------------------------------------------------
Fax | 910-642-5929
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEFFREY ALAN CLARKE
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 910-642-2230
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 101710
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------