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

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 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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