Provider Demographics
NPI:1346353869
Name:HOLLY SPRINGS FAMILY PRACTICE
Entity Type:Organization
Organization Name:HOLLY SPRINGS FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:S
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-786-7966
Mailing Address - Street 1:104 ARARAT LONG HILL RD
Mailing Address - Street 2:
Mailing Address - City:PILOT MOUNTAIN
Mailing Address - State:NC
Mailing Address - Zip Code:27041-8113
Mailing Address - Country:US
Mailing Address - Phone:336-786-7966
Mailing Address - Fax:336-786-1601
Practice Address - Street 1:104 ARARAT LONG HILL RD
Practice Address - Street 2:
Practice Address - City:PILOT MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:27041-8113
Practice Address - Country:US
Practice Address - Phone:336-786-7966
Practice Address - Fax:336-786-1601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8948063Medicaid
NC8948063Medicaid
NC2155120BMedicare ID - Type Unspecified