Provider Demographics
NPI:1477583102
Name:TYRRELL COUNTY RURAL HEALTH ASSOCIATION, INC.
Entity Type:Organization
Organization Name:TYRRELL COUNTY RURAL HEALTH ASSOCIATION, INC.
Other - Org Name:DBA - COLUMBIA MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEIBENSPERGER-CAVALL
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:252-796-0689
Mailing Address - Street 1:208 NORTH BROAD ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:NC
Mailing Address - Zip Code:27925-9705
Mailing Address - Country:US
Mailing Address - Phone:252-796-0689
Mailing Address - Fax:252-796-0690
Practice Address - Street 1:208 NORTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:NC
Practice Address - Zip Code:27925
Practice Address - Country:US
Practice Address - Phone:252-796-0689
Practice Address - Fax:252-796-0690
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343923Medicare ID - Type Unspecified