1215499520 NPI number — CHARLOTTE COMMUNITY HEALTH CLINIC, INC.

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 1215499520 NPI number — CHARLOTTE COMMUNITY HEALTH CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHARLOTTE COMMUNITY HEALTH CLINIC, INC.
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:
CHARLOTTE COMMUNITY HEALTH CLINIC FAMILY DENTISTRY
Provider Other Organization Name Type Code:
3
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:
1215499520
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/16/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5301 WILKINSON BLVD STE 1105
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:
28208-5455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-316-6562
Provider Business Mailing Address Fax Number:
704-384-1977

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5301 WILKINSON BLVD STE 1105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28208-5455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-316-6573
Provider Business Practice Location Address Fax Number:
704-384-1977
Provider Enumeration Date:
04/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HOLMES
Authorized Official First Name:
LISA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
704-316-6561

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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