1376976878 NPI number — NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC

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 1376976878 NPI number — NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC
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:
1376976878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7940 WILLIAMS POND LN
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-8766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-752-7779
Provider Business Mailing Address Fax Number:
704-752-7775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7940 WILLIAMS POND LN
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-8766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-752-7779
Provider Business Practice Location Address Fax Number:
704-752-7775
Provider Enumeration Date:
08/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SHAW
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
704-752-7779

Provider Taxonomy Codes

  • Taxonomy code: 207QB0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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