Provider Demographics
NPI:1609260942
Name:TIMA WELLNESS PA
Entity Type:Organization
Organization Name:TIMA WELLNESS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BYRON
Authorized Official - Middle Name:
Authorized Official - Last Name:GLADDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:336-907-3006
Mailing Address - Street 1:1591 YANCEYVILLE STREET
Mailing Address - Street 2:SUITE 200A
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6941
Mailing Address - Country:US
Mailing Address - Phone:336-907-3006
Mailing Address - Fax:336-230-1761
Practice Address - Street 1:1591 YANCEYVILLE STREET
Practice Address - Street 2:SUITE 200A
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6941
Practice Address - Country:US
Practice Address - Phone:336-907-3006
Practice Address - Fax:336-663-8421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-25
Last Update Date:2017-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC95-01417207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8975633Medicaid
NC2219644AMedicare PIN
NCG19903Medicare UPIN