1962781047 NPI number — MR. JIMMY WAYNE CARPENTER C.PED

Table of content: (NPI 1811717747)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962781047 NPI number — MR. JIMMY WAYNE CARPENTER C.PED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARPENTER
Provider First Name:
JIMMY
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
C.PED
Provider Gender Code:
M

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:
1962781047
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4807 EDINBOROUGH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GREENSBORO
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27406-8322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-674-6422
Provider Business Mailing Address Fax Number:
336-674-2282

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4500 INDIANA AVE STE 45
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINSTON SALEM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27106-3269
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-245-4736
Provider Business Practice Location Address Fax Number:
888-812-7934
Provider Enumeration Date:
08/08/2011

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: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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