Provider Demographics
NPI:1316970593
Name:FAYETTEVILLE VA HOSPITAL
Entity type:Organization
Organization Name:FAYETTEVILLE VA HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED RESPIRATORY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:UPDEGGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:RTT
Authorized Official - Phone:910-488-2120
Mailing Address - Street 1:4104 NASHVILLE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-9278
Mailing Address - Country:US
Mailing Address - Phone:910-424-7282
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital