Provider Demographics
NPI:1093177404
Name:HEREDITARY CARE CENTER
Entity Type:Organization
Organization Name:HEREDITARY CARE CENTER
Other - Org Name:HEREDITARY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROBERTS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:919-847-7475
Mailing Address - Street 1:10941 RAVEN RIDGE RD
Mailing Address - Street 2:SUITE 107
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-6487
Mailing Address - Country:US
Mailing Address - Phone:919-256-2526
Mailing Address - Fax:919-847-7471
Practice Address - Street 1:10941 RAVEN RIDGE RD
Practice Address - Street 2:SUITE 107
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-6487
Practice Address - Country:US
Practice Address - Phone:919-256-2526
Practice Address - Fax:919-847-7471
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GYNECOLOGY & LAPAROSCOPIC SURGEONS, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
170300000X, 261QG0250X
NC9701567207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QG0250XAmbulatory Health Care FacilitiesClinic/CenterGeneticsGroup - Multi-Specialty
No170300000XOther Service ProvidersGenetic Counselor, MSGroup - Multi-Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Multi-Specialty