1629223565 NPI number — PROCURE THERAPEUTIC AGENCY, INC

Table of content: (NPI 1629223565)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629223565 NPI number — PROCURE THERAPEUTIC AGENCY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROCURE THERAPEUTIC AGENCY, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629223565
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/13/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 620157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28262-0102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-910-1122
Provider Business Mailing Address Fax Number:
704-910-1139

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2301 W MOREHEAD ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28208-5271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-910-1122
Provider Business Practice Location Address Fax Number:
704-910-1139
Provider Enumeration Date:
11/19/2008

Additional Information

Authorized Official

Authorized Official Last Name:
FRIERSON
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
DEWAYNE
Authorized Official Title or Position:
OWNER/CEO
Authorized Official Telephone Number:
704-910-1122

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6008198 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3410183 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5915392 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8302580 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com