1235347378 NPI number — NORTHLAKE CHILDREN'S ASSOCIATES, P.A.

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 1235347378 NPI number — NORTHLAKE CHILDREN'S ASSOCIATES, P.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHLAKE CHILDREN'S ASSOCIATES, P.A.
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:
1235347378
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170A MEDICAL PARK RD
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
MOORESVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28117
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-663-5240
Provider Business Mailing Address Fax Number:
704-663-5399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170A MEDICAL PARK RD
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
MOORESVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28117
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-663-5240
Provider Business Practice Location Address Fax Number:
704-663-5399
Provider Enumeration Date:
05/21/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SCHIPPER
Authorized Official First Name:
BRITTANY
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE/CLINICAL MANAGER
Authorized Official Telephone Number:
704-663-5240

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 89011NT , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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