Provider Demographics
NPI:1619279247
Name:MAIN STREET FAMILY PRACTICE OF CHINA GROVE PC
Entity Type:Organization
Organization Name:MAIN STREET FAMILY PRACTICE OF CHINA GROVE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:PURCELL-REID
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:704-857-8769
Mailing Address - Street 1:302 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CHINA GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28023-2471
Mailing Address - Country:US
Mailing Address - Phone:704-857-8769
Mailing Address - Fax:704-857-8779
Practice Address - Street 1:302 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHINA GROVE
Practice Address - State:NC
Practice Address - Zip Code:28023-2471
Practice Address - Country:US
Practice Address - Phone:704-857-8769
Practice Address - Fax:704-857-8779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty