1922310754 NPI number — PARK ROAD HEALTH AND WELLNESS INC

Table of content: SOSA VARGHESE KOCHERIL MBBS (NPI 1760567374)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922310754 NPI number — PARK ROAD HEALTH AND WELLNESS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARK ROAD HEALTH AND WELLNESS 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:
1922310754
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4312 PARK RD
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:
28209-2271
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-523-2367
Provider Business Mailing Address Fax Number:
704-523-9937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4312 PARK RD
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:
28209-2271
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-523-2367
Provider Business Practice Location Address Fax Number:
704-523-9937
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HOZJAN
Authorized Official First Name:
JEREMY
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-523-2367

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4049 , 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)





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