Provider Demographics
NPI:1225760325
Name:THERAQUE
Entity Type:Organization
Organization Name:THERAQUE
Other - Org Name:THERAQUE HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:WYSOCKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-828-7117
Mailing Address - Street 1:301 GOVERNMENT CENTER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-1796
Mailing Address - Country:US
Mailing Address - Phone:910-828-7117
Mailing Address - Fax:910-828-7118
Practice Address - Street 1:301 GOVERNMENT CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-1796
Practice Address - Country:US
Practice Address - Phone:910-828-7117
Practice Address - Fax:910-828-7118
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1800XAmbulatory Health Care FacilitiesClinic/CenterCorporate Health
No2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive MedicineGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health