Provider Demographics
NPI:1477671980
Name:NEUROLOGY CENTER OF LUMBERTON INC
Entity Type:Organization
Organization Name:NEUROLOGY CENTER OF LUMBERTON INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:INDRA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GATIWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-739-2343
Mailing Address - Street 1:785 OAKRIDGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2325
Mailing Address - Country:US
Mailing Address - Phone:910-739-2343
Mailing Address - Fax:910-739-2338
Practice Address - Street 1:785 OAKRIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2325
Practice Address - Country:US
Practice Address - Phone:910-739-2343
Practice Address - Fax:910-739-2338
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-26
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC96-00919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790112UMedicaid
NC2338343Medicare PIN
NCF92486Medicare UPIN