Provider Demographics
NPI:1093813842
Name:PENSLOW HEALTH CLINIC INC
Entity Type:Organization
Organization Name:PENSLOW HEALTH CLINIC INC
Other - Org Name:PENSLOW MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:B
Authorized Official - Last Name:HINES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-329-7591
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:HOLLY RIDGE
Mailing Address - State:NC
Mailing Address - Zip Code:28445
Mailing Address - Country:US
Mailing Address - Phone:910-329-7591
Mailing Address - Fax:910-329-1592
Practice Address - Street 1:206 N DYSON ST
Practice Address - Street 2:
Practice Address - City:HOLLY RIDGE
Practice Address - State:NC
Practice Address - Zip Code:28445
Practice Address - Country:US
Practice Address - Phone:910-329-7591
Practice Address - Fax:910-329-1592
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3438034AMedicaid
NC313803CMedicaid
NC3438034AMedicaid
NC313803CMedicaid