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General NPI Number Information
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NPI Number | 1992701445
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Entity Type | Organization
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Legal Business Name | SOUTHFORK PEDIATRICS, PLLC
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Dates
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Enumeration Date | 06/21/2005
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1733 CONNELLY SPRINGS RD
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City | LENOIR
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State | NC
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Zip | 28645-7827
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Country | US
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Telephone | 828-726-8885
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Fax | 828-726-8883
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Provider Business Mailing Address
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Address Line | 1733 CONNELLY SPRINGS RD
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City | LENOIR
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State | NC
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Zip | 28645-7827
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Country | US
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Telephone | 828-726-8885
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Fax | 828-726-8883
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. DEBRA K BROWN
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Credential |
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Telephone | 828-726-1379
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | 9701479
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License Number State | NC
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