Provider Demographics
NPI:1750557237
Name:BLADEN HEALTHCARE, LLC
Entity type:Organization
Organization Name:BLADEN HEALTHCARE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:MASTERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-862-5178
Mailing Address - Street 1:501 S POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-9375
Mailing Address - Country:US
Mailing Address - Phone:910-862-5179
Mailing Address - Fax:910-862-5129
Practice Address - Street 1:501 S POPLAR ST
Practice Address - Street 2:
Practice Address - City:ELIZABETHTOWN
Practice Address - State:NC
Practice Address - Zip Code:28337-9375
Practice Address - Country:US
Practice Address - Phone:910-862-5179
Practice Address - Fax:910-862-5129
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BLADEN HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCH0154261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8907624Medicaid
NC8907624Medicaid