1417052986 NPI number — CENTER FOR FACIAL PLASTIC AND LASER SURGERY

Table of content: JULIO ALEJANDRO CHALELA MD (NPI 1548200371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417052986 NPI number — CENTER FOR FACIAL PLASTIC AND LASER SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTER FOR FACIAL PLASTIC AND LASER SURGERY
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:
M SEAN FREEMAN MD
Provider Other Organization Name Type Code:
5
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:
1417052986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11220 ELM LANE
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-543-1110
Provider Business Mailing Address Fax Number:
704-543-0898

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11220 ELM LANE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-543-1110
Provider Business Practice Location Address Fax Number:
704-543-0898
Provider Enumeration Date:
09/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FREEMAN
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
SEAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-543-1110

Provider Taxonomy Codes

  • Taxonomy code: 207YX0905X , with the licence number:  32239 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 33874 . This is a "BCBS BLUE CROSS BLUE SHIE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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