Provider Demographics
NPI:1497722359
Name:ESPIRITU CLINIC PLLC
Entity Type:Organization
Organization Name:ESPIRITU CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HERNANE
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:ESPIRITU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-898-7130
Mailing Address - Street 1:2425 N CENTER ST
Mailing Address - Street 2:370
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-1320
Mailing Address - Country:US
Mailing Address - Phone:888-898-7130
Mailing Address - Fax:828-322-7921
Practice Address - Street 1:715 FAIRGROVE CHURCH RD SE
Practice Address - Street 2:SUITE 204
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-9290
Practice Address - Country:US
Practice Address - Phone:888-898-7130
Practice Address - Fax:828-322-7921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-28
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891352XMedicaid
NC891352XMedicaid