Provider Demographics
NPI:1457686891
Name:OUTERBANKS PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:OUTERBANKS PROFESSIONAL SERVICES LLC
Other - Org Name:DARE MEDICAL ASSOCIATES
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:VAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-449-4500
Mailing Address - Street 1:604 AMANDA ST
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-9039
Mailing Address - Country:US
Mailing Address - Phone:252-473-3478
Mailing Address - Fax:252-473-3600
Practice Address - Street 1:604 AMANDA ST
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954-9039
Practice Address - Country:US
Practice Address - Phone:252-473-3478
Practice Address - Fax:252-473-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty