Provider Demographics
NPI:1366589483
Name:COUNTY OF DAVIDSON
Entity type:Organization
Organization Name:COUNTY OF DAVIDSON
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONTZ
Authorized Official - Suffix:
Authorized Official - Credentials:MPA, REHS
Authorized Official - Phone:336-242-2349
Mailing Address - Street 1:915 GREENSBORO ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292
Mailing Address - Country:US
Mailing Address - Phone:336-242-2300
Mailing Address - Fax:336-242-2485
Practice Address - Street 1:915 N GREENSBORO ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-2699
Practice Address - Country:US
Practice Address - Phone:336-242-2300
Practice Address - Fax:336-242-2485
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COUNTY OF DAVIDSON
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-30
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QC1500X, 251B00000X, 251K00000X, 261QF0050X, 261QM2500X, 261QP0905X, 261QP0905X
NC34D1058572291U00000X
NC34D0865330291U00000X
NC038613336C0002X, 3336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No251B00000XAgenciesCase Management
No251K00000XAgenciesPublic Health or Welfare
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical
No291U00000XLaboratoriesClinical Medical Laboratory
No3336C0002XSuppliersPharmacyClinic Pharmacy
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC00602OtherHEALTHY BLUE NC
NC600001182OtherRR MEDICARE
NC3404329Medicaid
NC81671OtherACNC
NC024YNOtherBCBS HEALTH CHOICE
NC1844OtherWELLCARE
NC87726OtherUHC-COMMUNITY PLAN
NC000042052001OtherUNITED HEALTH CARE