Provider Demographics
NPI:1093107542
Name:WATAUGA MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:WATAUGA MEDICAL CENTER, INC.
Other - Org Name:OP IMAGING & LAB CENTER - WILMA REDMONT BREAST CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR VP MEDICAL STAFF RELATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:ETTA
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-262-4133
Mailing Address - Street 1:336 DEERFIELD RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5008
Mailing Address - Country:US
Mailing Address - Phone:828-262-4100
Mailing Address - Fax:828-262-4103
Practice Address - Street 1:1200 STATE FARM RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4994
Practice Address - Country:US
Practice Address - Phone:828-266-2492
Practice Address - Fax:828-266-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2021-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QR0200X, 261QR0206X
NCH0077291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography