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General NPI Number Information
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NPI Number | 1992802128
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Entity Type | Organization
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Legal Business Name | PRIVATE DIAGNOSTIC CLINIC, PLLC
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Dates
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Enumeration Date | 09/20/2006
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Last Update Date | 07/11/2022
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Provider Practice Location Address
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Address Line | 2025 FRONTIS PLAZA BLVD SUITE 100
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City | WINSTON SALEM
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State | NC
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Zip | 27103-5663
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Country | US
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Telephone | 336-768-3240
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 110566
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City | DURHAM
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State | NC
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Zip | 27709-5566
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Country | US
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Telephone | 919-620-4855
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Fax | 919-620-4921
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Authorized Official
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Title or Position | CFO
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Name | CHRISTOPHER THOMAS FREDERICK
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Credential |
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Telephone | 919-613-7762
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number |
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License Number State |
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