1114205457 NPI number — LAKE NORMAN ENDOCRINOLOGY & DIABETES, PC

Table of content: (NPI 1114205457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114205457 NPI number — LAKE NORMAN ENDOCRINOLOGY & DIABETES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKE NORMAN ENDOCRINOLOGY & DIABETES, PC
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:
1114205457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
143 JOE KNOX AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117-9243
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-664-2936
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
143 JOE KNOX AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117-9243
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-664-2936
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2011

Additional Information

Authorized Official

Authorized Official Last Name:
OBI
Authorized Official First Name:
AUGUSTINE
Authorized Official Middle Name:
U
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
704-664-2910

Provider Taxonomy Codes

  • Taxonomy code: 207RE0101X , with the licence number:  9400602 , 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: 5918299 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com