Provider Demographics
NPI:1730670951
Name:FORSYTH COMMUNITY PCC LLC
Entity Type:Organization
Organization Name:FORSYTH COMMUNITY PCC LLC
Other - Org Name:HIGHLAND AVENUE PRIMARY CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:RCS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEEA
Authorized Official - Middle Name:JEANINE
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-316-6081
Mailing Address - Street 1:PO BOX 603582
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3582
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 HIGHLAND AVE STE 120
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4304
Practice Address - Country:US
Practice Address - Phone:336-718-4770
Practice Address - Fax:336-718-4779
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-23
Last Update Date:2023-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty