Provider Demographics
NPI:1639625106
Name:FAYETTEVILLE AREA HEALTH EDUCATION FOUNDATION, INC.
Entity Type:Organization
Organization Name:FAYETTEVILLE AREA HEALTH EDUCATION FOUNDATION, INC.
Other - Org Name:SOUTHERN REGIONAL AHEC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP CEAS
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSHMA
Authorized Official - Middle Name:
Authorized Official - Last Name:KAPOOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-678-0100
Mailing Address - Street 1:1601 OWEN DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-3425
Mailing Address - Country:US
Mailing Address - Phone:910-678-0100
Mailing Address - Fax:910-678-0115
Practice Address - Street 1:1601 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3425
Practice Address - Country:US
Practice Address - Phone:910-678-0100
Practice Address - Fax:910-678-0115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-25
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004639261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care