Provider Demographics
NPI:1811140494
Name:MCKEITHAN HEALTH, PA
Entity type:Organization
Organization Name:MCKEITHAN HEALTH, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:MCKEITHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-253-7990
Mailing Address - Street 1:PO BOX 409
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-0409
Mailing Address - Country:US
Mailing Address - Phone:910-253-7990
Mailing Address - Fax:
Practice Address - Street 1:3875 BUSINESS 17 E
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-8666
Practice Address - Country:US
Practice Address - Phone:910-253-7990
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC105024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty