1114088416 NPI number — STAT ETC, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114088416 NPI number — STAT ETC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STAT ETC, 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:
6
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:
1114088416
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 29562
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:
28229-9562
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-217-5231
Provider Business Mailing Address Fax Number:
919-400-4201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4917 ALBEMARLE RD STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28205-6686
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-217-5231
Provider Business Practice Location Address Fax Number:
919-400-4201
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WYLIE
Authorized Official First Name:
LOLETTA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
980-217-5231

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  HC3156 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100577 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3418002 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6601380 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 6800485 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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