Provider Demographics
NPI:1982905832
Name:FDW FAMILY CARE CENTER, PLLC
Entity Type:Organization
Organization Name:FDW FAMILY CARE CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JEVITA
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:TERRY
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:252-210-3457
Mailing Address - Street 1:3068 SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-3647
Mailing Address - Country:US
Mailing Address - Phone:252-210-3457
Mailing Address - Fax:252-210-3461
Practice Address - Street 1:3068 SUNSET AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-3647
Practice Address - Country:US
Practice Address - Phone:252-210-3457
Practice Address - Fax:252-210-3461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-09
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC120969261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care