Provider Demographics
NPI:1659501930
Name:GOLDSBORO WELLNESS CENTER,PA
Entity Type:Organization
Organization Name:GOLDSBORO WELLNESS CENTER,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:R
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:919-778-1676
Mailing Address - Street 1:2600 US HIGHWAY 70 W
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-7779
Mailing Address - Country:US
Mailing Address - Phone:919-739-4808
Mailing Address - Fax:919-739-4810
Practice Address - Street 1:1100 PARKWAY DR
Practice Address - Street 2:SUITE C
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-3477
Practice Address - Country:US
Practice Address - Phone:919-778-7665
Practice Address - Fax:919-778-7665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-21
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG95748Medicare UPIN