Provider Demographics
NPI:1114921137
Name:FAMILY CARE HEALTH AND WELLNESS CENTER, INC.
Entity Type:Organization
Organization Name:FAMILY CARE HEALTH AND WELLNESS CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:SANDRA
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-723-9002
Mailing Address - Street 1:1430 HSA LN
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-2048
Mailing Address - Country:US
Mailing Address - Phone:336-723-9002
Mailing Address - Fax:336-722-3780
Practice Address - Street 1:1430 HSA LN
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-2048
Practice Address - Country:US
Practice Address - Phone:336-723-9002
Practice Address - Fax:336-722-3780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890162KMedicaid
NC2313649Medicare ID - Type Unspecified
NC4658150001Medicare NSC