Provider Demographics
NPI:1073860045
Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Entity Type:Organization
Organization Name:PRIVATE DIAGNOSTIC CLINIC, PLLC
Other - Org Name:DUKE CARDIOLOGY PEMBROKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF COMPLIANCE, PRIVACY & AUDIT
Authorized Official - Prefix:
Authorized Official - First Name:VALLA
Authorized Official - Middle Name:FABRAE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-668-5161
Mailing Address - Street 1:PO BOX 110566
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27709-5566
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:919-620-4921
Practice Address - Street 1:812 CANDY PARK RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-9129
Practice Address - Country:US
Practice Address - Phone:910-671-6619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-09
Last Update Date:2022-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty