Taxonomy Codes
The NPI record includes the healthcare provider taxonomy classification, state license number and state of licensure. The following information regarding the scope of practice of this provider is available:
| No. |
Taxonomy Code |
Taxonomy Clasification |
Taxonomy Specialization |
License Number |
License State |
Primary |
| 1 | 251K00000X | Public Health or Welfare | | N/A | | No |
| 2 | 261QP0905X | Clinic/Center | Public Health, State or Local | | | Yes |
Other Identifiers
The following information regarding additional identifiers associated to this NPI record includes the other identifier number, identifier type, identifier state and issuer.
| No. |
Other Provider Identifier |
Other Provider Identifier Type |
Other Provider Identifier State |
Other Provider Identifier Issuer |
| 1 | 3404433 | MEDICAID | NORTH CAROLINA | |
| 2 | 3404342 | MEDICAID | NORTH CAROLINA | |
| 3 | 2270475 | OTHER | NORTH CAROLINA | CIGNA MANAGED CARE |
| 4 | 07216 | OTHER | NORTH CAROLINA | BLUE CROSS BLUE SHIELD |
| 5 | 79929 | OTHER | NORTH CAROLINA | MEDCOST NETWORK |
| 6 | 6005545 | MEDICAID | NORTH CAROLINA | |
| 7 | E526 | MEDICARE PIN | NORTH CAROLINA | |
