Provider Demographics
NPI:1427232735
Name:MECKLENBURG FAMILY PRACTICE
Entity Type:Organization
Organization Name:MECKLENBURG FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLOUGHBY
Authorized Official - Middle Name:SHELTON
Authorized Official - Last Name:HUNDLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:434-738-6911
Mailing Address - Street 1:PO BOX 297
Mailing Address - Street 2:
Mailing Address - City:BOYDTON
Mailing Address - State:VA
Mailing Address - Zip Code:23917-0297
Mailing Address - Country:US
Mailing Address - Phone:434-738-6911
Mailing Address - Fax:434-738-0431
Practice Address - Street 1:969 MADISON ST
Practice Address - Street 2:
Practice Address - City:BOYDTON
Practice Address - State:VA
Practice Address - Zip Code:23917-0297
Practice Address - Country:US
Practice Address - Phone:434-738-6911
Practice Address - Fax:434-738-0431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care