Provider Demographics
NPI:1811209901
Name:WESTERN WAKE INTERNAL MEDICINE
Entity Type:Organization
Organization Name:WESTERN WAKE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:KENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:HEINE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:858-625-2990
Mailing Address - Street 1:5810 NANCY RIDGE DR
Mailing Address - Street 2:100
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92121-2834
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:907 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-3922
Practice Address - Country:US
Practice Address - Phone:919-319-6610
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDVANTX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-07-06
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801744332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site