Provider Demographics
NPI:1760417570
Name:WAYNESBORO FAMILY CLINIC
Entity Type:Organization
Organization Name:WAYNESBORO FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:NITA
Authorized Official - Middle Name:
Authorized Official - Last Name:VANNOSKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-734-6676
Mailing Address - Street 1:1706 WAYNE MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-2240
Mailing Address - Country:US
Mailing Address - Phone:919-734-6676
Mailing Address - Fax:919-734-9050
Practice Address - Street 1:1706 WAYNE MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2240
Practice Address - Country:US
Practice Address - Phone:919-734-6676
Practice Address - Fax:919-734-9050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC34D2077478291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015MKMedicaid
NC8300477Medicaid
NC8300477BMedicaid
NC6005103Medicaid
NC3410001Medicaid
NC8300477GMedicaid
NC6005103Medicaid
NC3410001Medicaid