1205999687 NPI number — CAROLINA SKIN CARE, PA

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 1205999687 NPI number — CAROLINA SKIN CARE, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAROLINA SKIN CARE, PA
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:
1205999687
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
125 FOX HOLLOW RD
Provider Second Line Business Mailing Address:
STE 210
Provider Business Mailing Address City Name:
PINEHURST
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28374-8511
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
910-295-7546
Provider Business Mailing Address Fax Number:
910-692-2831

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
125 FOX HOLLOW RD
Provider Second Line Business Practice Location Address:
STE 210
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28374-8511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-295-7546
Provider Business Practice Location Address Fax Number:
910-692-2831
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLUMPAR
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
IVAN
Authorized Official Title or Position:
CEO PRESIDENT
Authorized Official Telephone Number:
910-295-7546

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  34653 , 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: 0153Y . This is a "BLUECROSSBLUESHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8949708 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: CE7551 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 1730283276 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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