Provider Demographics
NPI:1225238009
Name:WINTERGREEN MEDICAL CENTER, PLLC
Entity Type:Organization
Organization Name:WINTERGREEN MEDICAL CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:CALVIN
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:252-551-5595
Mailing Address - Street 1:324-A BEACON DR
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-7956
Mailing Address - Country:US
Mailing Address - Phone:252-551-5595
Mailing Address - Fax:252-321-7762
Practice Address - Street 1:324A BEACON DR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-7956
Practice Address - Country:US
Practice Address - Phone:252-551-5595
Practice Address - Fax:252-321-7762
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WINTERGREEN MEDICAL CENTER, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-20
Last Update Date:2016-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141455261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8976432Medicaid
NC8976432Medicaid