Provider Demographics
NPI:1376854083
Name:ADVANCE FAMILY AND SPORTS MEDICINE CENTER, PLLC
Entity type:Organization
Organization Name:ADVANCE FAMILY AND SPORTS MEDICINE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:
Authorized Official - Last Name:EZEIGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-940-2659
Mailing Address - Street 1:169 YADKIN VALLEY RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ADVANCE
Mailing Address - State:NC
Mailing Address - Zip Code:27006-8786
Mailing Address - Country:US
Mailing Address - Phone:336-940-2659
Mailing Address - Fax:
Practice Address - Street 1:169 YADKIN VALLEY RD
Practice Address - Street 2:SUITE 101
Practice Address - City:ADVANCE
Practice Address - State:NC
Practice Address - Zip Code:27006-8786
Practice Address - Country:US
Practice Address - Phone:336-940-2659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-28
Last Update Date:2010-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty