Provider Demographics
NPI:1043558745
Name:OLDTOWN MEDICAL CARE, LLC
Entity Type:Organization
Organization Name:OLDTOWN MEDICAL CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:276-236-5300
Mailing Address - Street 1:306 MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-3020
Mailing Address - Country:US
Mailing Address - Phone:276-236-5300
Mailing Address - Fax:
Practice Address - Street 1:306 MEADOW ST
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333
Practice Address - Country:US
Practice Address - Phone:276-236-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-30
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty