Provider Demographics
NPI:1730795493
Name:MOUNTAIN PARK FAMILY PRACTICE, PLLC
Entity type:Organization
Organization Name:MOUNTAIN PARK FAMILY PRACTICE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/ORGANIZER
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:828-631-3181
Mailing Address - Street 1:90 E MAIN ST STE 2
Mailing Address - Street 2:
Mailing Address - City:SYLVA
Mailing Address - State:NC
Mailing Address - Zip Code:28779-3030
Mailing Address - Country:US
Mailing Address - Phone:828-631-3181
Mailing Address - Fax:828-631-6113
Practice Address - Street 1:90 E MAIN ST STE 2
Practice Address - Street 2:
Practice Address - City:SYLVA
Practice Address - State:NC
Practice Address - Zip Code:28779-3030
Practice Address - Country:US
Practice Address - Phone:828-631-3181
Practice Address - Fax:828-631-6113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-18
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1215377908Medicaid