Provider Demographics
NPI:1518625607
Name:LIVING THE BREAMEDICAL - EDENTON, PLLC
Entity Type:Organization
Organization Name:LIVING THE BREAMEDICAL - EDENTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:ATKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-501-1095
Mailing Address - Street 1:PO BOX 808
Mailing Address - Street 2:
Mailing Address - City:STOKESDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27357-0808
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:314 W QUEEN ST
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-1733
Practice Address - Country:US
Practice Address - Phone:252-702-0267
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-06
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care