1073574109 NPI number — MS. ELIZABETH LAX WATSON OTR

Table of content: MS. ELIZABETH LAX WATSON OTR (NPI 1073574109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073574109 NPI number — MS. ELIZABETH LAX WATSON OTR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
ELIZABETH
Provider Middle Name:
LAX
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
OTR
Provider Gender Code:
F

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:
1073574109
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15446 ABBOTTS BRIDGE 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:
28277-2182
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-577-1091
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9129 MONROE RD
Provider Second Line Business Practice Location Address:
SUITE 100-105
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28270-2429
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-847-3911
Provider Business Practice Location Address Fax Number:
704-847-2033
Provider Enumeration Date:
03/29/2006

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: 225X00000X , with the licence number:  2483 , 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)

  • Identifier: 7301496 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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