Provider Demographics
NPI:1962650762
Name:CAH ACQUISITION COMPANY 1 LLC
Entity Type:Organization
Organization Name:CAH ACQUISITION COMPANY 1 LLC
Other - Org Name:PLYMOUTH PRIMARY CARE RURAL HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:TITUS
Authorized Official - Last Name:AVIGNONE
Authorized Official - Suffix:IV
Authorized Official - Credentials:
Authorized Official - Phone:214-502-9624
Mailing Address - Street 1:7920 BELT LINE RD STE 215
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8155
Mailing Address - Country:US
Mailing Address - Phone:214-502-9624
Mailing Address - Fax:252-793-7736
Practice Address - Street 1:1006 US HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962
Practice Address - Country:US
Practice Address - Phone:252-793-7701
Practice Address - Fax:252-793-7736
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAH ACQUISITION COMPANY 1 LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-04
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0006261QR1300X, 261QR1300X
207R00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343430A&CMedicaid
NC890233WOtherCAROLINA ACCESS
NC343430Medicare Oscar/Certification