Provider Demographics
NPI:1720104540
Name:VALDESE FAMILY PRACTICE, PA
Entity type:Organization
Organization Name:VALDESE FAMILY PRACTICE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:828-874-1316
Mailing Address - Street 1:99 GRIFFIN STREET
Mailing Address - Street 2:PO BOX 806
Mailing Address - City:RUTHERFORD COLLEGE
Mailing Address - State:NC
Mailing Address - Zip Code:28671
Mailing Address - Country:US
Mailing Address - Phone:828-874-1316
Mailing Address - Fax:828-874-1092
Practice Address - Street 1:99 GRIFFIN STREET
Practice Address - Street 2:
Practice Address - City:RUTHERFORD COLLEGE
Practice Address - State:NC
Practice Address - Zip Code:28671
Practice Address - Country:US
Practice Address - Phone:828-874-1316
Practice Address - Fax:828-874-1092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC79330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890195JMedicaid
NC0195JOtherNC BCBS GROUP NUMBER
NC890195JMedicaid