Provider Demographics
NPI:1164487823
Name:IMMANUEL FAMILY PRACTICE
Entity Type:Organization
Organization Name:IMMANUEL FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BETTI
Authorized Official - Middle Name:D
Authorized Official - Last Name:REESE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-856-9996
Mailing Address - Street 1:5500 W FRIENDLY AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-4212
Mailing Address - Country:US
Mailing Address - Phone:336-856-9996
Mailing Address - Fax:
Practice Address - Street 1:5500 W FRIENDLY AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-4212
Practice Address - Country:US
Practice Address - Phone:336-856-9996
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-18
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89016JVMedicaid
NC89016JVMedicaid