1164763777 NPI number — MR. CHARLES WAYNE ELLIS CACI, MAC

Table of content: MR. CHARLES WAYNE ELLIS CACI, MAC (NPI 1164763777)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164763777 NPI number — MR. CHARLES WAYNE ELLIS CACI, MAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLIS
Provider First Name:
CHARLES
Provider Middle Name:
WAYNE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CACI, MAC
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:
1164763777
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12304 JACQUELYN CT
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:
28273-9017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-575-6165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
199 S HERLONG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK HILL
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29732-1186
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-324-1800
Provider Business Practice Location Address Fax Number:
803-328-3831
Provider Enumeration Date:
03/06/2013

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: 101YA0400X , with the licence number:  1211149 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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