Provider Demographics
NPI:1124298773
Name:BLADEN LAKES COMMUNITY HEALTH CENTER
Entity type:Organization
Organization Name:BLADEN LAKES COMMUNITY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-567-6194
Mailing Address - Street 1:16526 NC HIGHWAY 87 W
Mailing Address - Street 2:
Mailing Address - City:TAR HEEL
Mailing Address - State:NC
Mailing Address - Zip Code:28392-8608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16526 NC HIGHWAY 87 W
Practice Address - Street 2:
Practice Address - City:TAR HEEL
Practice Address - State:NC
Practice Address - Zip Code:28392-8608
Practice Address - Country:US
Practice Address - Phone:910-972-5720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3336C0002X
NCNC100103336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
3410494OtherOTHER ID NUMBER