1376976878 NPI number — NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC

Table of content: (NPI 1376976878)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376976878 NPI number — NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC
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:
1376976878
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7940 WILLIAMS POND LN
Provider Second Line Business Mailing Address:
SUITE 150
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-8766
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-752-7779
Provider Business Mailing Address Fax Number:
704-752-7775

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7940 WILLIAMS POND LN
Provider Second Line Business Practice Location Address:
SUITE 150
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-8766
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-752-7779
Provider Business Practice Location Address Fax Number:
704-752-7775
Provider Enumeration Date:
08/20/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SHAW
Authorized Official First Name:
KATHRYN
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
MEDICAL DIRECTOR/OWNER
Authorized Official Telephone Number:
704-752-7779

Provider Taxonomy Codes

  • Taxonomy code: 207QB0002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com