Provider Demographics
NPI:1366047748
Name:TIGHT LINES FAMILY MEDICINE P.A.
Entity type:Organization
Organization Name:TIGHT LINES FAMILY MEDICINE P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:BRANDON
Authorized Official - Last Name:LUDLUM
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:910-538-9581
Mailing Address - Street 1:1902 MEETING CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-6631
Mailing Address - Country:US
Mailing Address - Phone:910-399-7180
Mailing Address - Fax:910-660-8314
Practice Address - Street 1:1902 MEETING CT
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-6631
Practice Address - Country:US
Practice Address - Phone:910-399-7180
Practice Address - Fax:910-660-8314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669918223Medicaid