Provider Demographics
NPI:1457319576
Name:WAKE TEEN MEDICAL SERVICES INC.
Entity Type:Organization
Organization Name:WAKE TEEN MEDICAL SERVICES INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-828-0038
Mailing Address - Street 1:505 OBERLIN RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-1397
Mailing Address - Country:US
Mailing Address - Phone:909-828-0035
Mailing Address - Fax:909-828-0355
Practice Address - Street 1:505 OBERLIN RD
Practice Address - Street 2:SUITE 204
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1397
Practice Address - Country:US
Practice Address - Phone:909-828-0035
Practice Address - Fax:909-828-0355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902730Medicaid
NC02730OtherNC BCBS GROUP NUMBER