Provider Demographics
NPI:1063653178
Name:EASTOVER PEDIATRICS
Entity Type:Organization
Organization Name:EASTOVER PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COMPLIANCE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:C
Authorized Official - Last Name:DUCKWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:CPC, CMIS, CMOM
Authorized Official - Phone:910-738-8060
Mailing Address - Street 1:400 LIBERTY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2446
Mailing Address - Country:US
Mailing Address - Phone:910-738-8060
Mailing Address - Fax:910-671-3600
Practice Address - Street 1:3551 DUNN RD
Practice Address - Street 2:SUITE 103
Practice Address - City:EASTOVER
Practice Address - State:NC
Practice Address - Zip Code:28312-8794
Practice Address - Country:US
Practice Address - Phone:910-738-8060
Practice Address - Fax:910-671-3600
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S HEALTH OF CAROLINA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-19
Last Update Date:2009-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty