Provider Demographics
NPI:1043512783
Name:CLEAR WATER MEDICAL LLC
Entity Type:Organization
Organization Name:CLEAR WATER MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:GORE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:910-465-2783
Mailing Address - Street 1:PO BOX 16310
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28408-6310
Mailing Address - Country:US
Mailing Address - Phone:910-465-2783
Mailing Address - Fax:910-794-4531
Practice Address - Street 1:4912 LAKE RENAISSANCE CIR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28409-3303
Practice Address - Country:US
Practice Address - Phone:910-465-2783
Practice Address - Fax:910-794-4531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty