Provider Demographics
NPI:1528139987
Name:CALABASH PRIMARY CARE LLC
Entity type:Organization
Organization Name:CALABASH PRIMARY CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:SELLERS
Authorized Official - Suffix:SR
Authorized Official - Credentials:NURSE PRACTICIONER
Authorized Official - Phone:910-575-6538
Mailing Address - Street 1:10195 BEACH DR SW # 5
Mailing Address - Street 2:
Mailing Address - City:CALABASH
Mailing Address - State:NC
Mailing Address - Zip Code:28467-2701
Mailing Address - Country:US
Mailing Address - Phone:910-575-6538
Mailing Address - Fax:910-575-6541
Practice Address - Street 1:10195 BEACH DR SW # 5
Practice Address - Street 2:
Practice Address - City:CALABASH
Practice Address - State:NC
Practice Address - Zip Code:28467-2701
Practice Address - Country:US
Practice Address - Phone:910-575-6538
Practice Address - Fax:910-575-6541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2009-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27331363A00000X
NC201575363L00000X
NC27938207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC203024OtherMEDICARE
NCDB2289OtherRAILROAD MEDICARE
NC10048OtherBLUE CROSS & BLUE SHIELD
NC89131FGMedicaid
SC098806Medicaid
NC8950904Medicaid
NC89131FGMedicaid
NC203024OtherMEDICARE
NC2592058BMedicare ID - Type Unspecified
NC2329882Medicare ID - Type Unspecified
NCP69056Medicare UPIN
NCQ15520Medicare UPIN