Provider Demographics
NPI:1265669535
Name:MOUNTAIN LAUREL FAMILY PRACTICE, PLLC
Entity Type:Organization
Organization Name:MOUNTAIN LAUREL FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCCLURE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-355-9624
Mailing Address - Street 1:222 LONGVUE DR
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-5060
Mailing Address - Country:US
Mailing Address - Phone:828-355-9624
Mailing Address - Fax:828-355-9626
Practice Address - Street 1:222 LONGVUE DR
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-5060
Practice Address - Country:US
Practice Address - Phone:828-355-9624
Practice Address - Fax:828-355-9626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-15
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200890363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty