Provider Demographics
NPI:1407007131
Name:WFUBMCCP PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:WFUBMCCP PRIMARY CARE, LLC
Other - Org Name:WAKE FOREST BAPTIST HEALTHCARE CENTER - DAVIE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:MCLAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:336-716-2817
Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-1209
Mailing Address - Country:US
Mailing Address - Phone:336-751-8304
Mailing Address - Fax:336-751-8402
Practice Address - Street 1:1188 YADKINVILLE RD
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2037
Practice Address - Country:US
Practice Address - Phone:336-751-8304
Practice Address - Fax:336-751-8402
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTH CAROLINA BAPTIST HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care