1396090155 NPI number — MRS. STACEY L GRETKA BSHN

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 1396090155 NPI number — MRS. STACEY L GRETKA BSHN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRETKA
Provider First Name:
STACEY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BSHN
Provider Gender Code:
F

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:
1396090155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/18/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 S TRYON ST
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28280-0002
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
980-254-8433
Provider Business Mailing Address Fax Number:
704-943-0720

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10130 MALLARD CREEK RD
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-6000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-549-9550
Provider Business Practice Location Address Fax Number:
704-549-9570
Provider Enumeration Date:
07/18/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133NN1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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