Provider Demographics
NPI:1760715486
Name:EXCELLENT SPIRIT ENTERPRISE, INC.
Entity Type:Organization
Organization Name:EXCELLENT SPIRIT ENTERPRISE, INC.
Other - Org Name:MEDICAL CLINIC OF SHARPSBURG
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:PICKETT
Authorized Official - Suffix:SR
Authorized Official - Credentials:DO
Authorized Official - Phone:252-446-4455
Mailing Address - Street 1:PO BOX 98
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:NC
Mailing Address - Zip Code:27878-0098
Mailing Address - Country:US
Mailing Address - Phone:252-446-4455
Mailing Address - Fax:704-625-0372
Practice Address - Street 1:9201 COUNTY LINE ROAD
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:NC
Practice Address - Zip Code:27878-9998
Practice Address - Country:US
Practice Address - Phone:252-446-4455
Practice Address - Fax:704-625-0372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-14
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000114261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC344644CMedicaid
NC344644AMedicaid
NC344644AMedicaid