Provider Demographics
NPI:1124467584
Name:WILMINGTON PROACTIVE MEDICINE, PA
Entity type:Organization
Organization Name:WILMINGTON PROACTIVE MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:APRIL
Authorized Official - Middle Name:
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-431-2512
Mailing Address - Street 1:1410 COMMONWEALTH DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-0314
Mailing Address - Country:US
Mailing Address - Phone:910-679-4784
Mailing Address - Fax:910-777-5453
Practice Address - Street 1:1410 COMMONWEALTH DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-0376
Practice Address - Country:US
Practice Address - Phone:910-679-4784
Practice Address - Fax:910-777-5453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9701146261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care