Provider Demographics
NPI:1659460624
Name:DAVIE COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:DAVIE COUNTY HEALTH DEPARTMENT
Other - Org Name:CLINIC CENTER MEDICAL SPECIALTY
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:B
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:336-751-8700
Mailing Address - Street 1:PO BOX 848
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-0848
Mailing Address - Country:US
Mailing Address - Phone:336-751-8700
Mailing Address - Fax:336-751-0335
Practice Address - Street 1:210 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2039
Practice Address - Country:US
Practice Address - Phone:336-751-8700
Practice Address - Fax:336-751-0335
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 261QM1300X, 261QM2500X, 261QP0905X, 291U00000X
NC044653336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Not Answered261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Not Answered261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Not Answered291U00000XLaboratoriesClinical Medical Laboratory
Not Answered3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3404459Medicaid