1063403160 NPI number — CHARLENE LYDIA BLAINE

Table of content: REBECCA LUNDY (NPI 1932689627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063403160 NPI number — CHARLENE LYDIA BLAINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLENE LYDIA BLAINE
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:
6
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:
1063403160
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11048 CLEVELAND ROAD
Provider Second Line Business Mailing Address:
SUITE 101-102
Provider Business Mailing Address City Name:
GARNER
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27529
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-359-9920
Provider Business Mailing Address Fax Number:
919-359-2520

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11048 CLEVELAND ROAD
Provider Second Line Business Practice Location Address:
SUITE 101-102
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-359-9920
Provider Business Practice Location Address Fax Number:
919-359-2520
Provider Enumeration Date:
10/31/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BLAINE
Authorized Official First Name:
CHARLENE
Authorized Official Middle Name:
LYDIA
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-359-9920

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  9500533 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RS0012X , with the licence number: 9500533 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2278P1004X , with the licence number: A-4125 , 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: 017PY . This is a "BCBSNC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 37119 . This is a "PARTNERS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 429202 . This is a "WELLPATH" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 3500316 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 5902258 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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