Provider Demographics
NPI:1689637225
Name:RAEFORD FAMILY CARE CENTER PC
Entity Type:Organization
Organization Name:RAEFORD FAMILY CARE CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:FARMER
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:910-875-4545
Mailing Address - Street 1:PO BOX 1041
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28359-1041
Mailing Address - Country:US
Mailing Address - Phone:910-738-5850
Mailing Address - Fax:910-738-5855
Practice Address - Street 1:1090 E CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3039
Practice Address - Country:US
Practice Address - Phone:910-875-4545
Practice Address - Fax:910-875-8972
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-06
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-01721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014TXMedicaid
NC014TXOtherNC BCBS
NC2333687Medicare ID - Type UnspecifiedCIGNA MEDICARE