1962521823 NPI number — INREACH

Table of content: L SCOTT BRODY D.D.S. P.C (NPI 1508877333)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962521823 NPI number — INREACH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INREACH
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:
1962521823
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/20/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4530 PARK RD STE 300
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:
28209-3790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-536-6661
Provider Business Mailing Address Fax Number:
704-536-0074

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4922 GREYWOOD DR
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:
28212-4826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-563-0105
Provider Business Practice Location Address Fax Number:
704-536-0074
Provider Enumeration Date:
03/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GOUGEON
Authorized Official First Name:
LORI
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
704-536-6661

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 311ZA0620X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320600000X , with the licence number: MHL060-157 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 7802264 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: MHL-060-157 . This is a "NC DEPARTMENT OF HEALTH AND HUMAN SERVICES" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".