Provider Demographics
NPI:1306967880
Name:HEARTWORKS CHILDRENS MEDICAL HOME MISSION
Entity type:Organization
Organization Name:HEARTWORKS CHILDRENS MEDICAL HOME MISSION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LINDSEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-745-4510
Mailing Address - Street 1:PO BOX 365
Mailing Address - Street 2:
Mailing Address - City:BAYBORO
Mailing Address - State:NC
Mailing Address - Zip Code:28515-0365
Mailing Address - Country:US
Mailing Address - Phone:252-745-4510
Mailing Address - Fax:252-745-4511
Practice Address - Street 1:205 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BAYBORO
Practice Address - State:NC
Practice Address - Zip Code:28515
Practice Address - Country:US
Practice Address - Phone:252-745-4510
Practice Address - Fax:252-745-4511
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEARTWORKS CHILDRENS MEDICAL HOME MISSION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-03
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016WUOtherBLUE CROSS GROUP NUMBER
NC6005232Medicaid