1407271109 NPI number — CENTRAL CAROLINA MEDICAL CLINIC, PA

Table of content: (NPI 1407271109)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407271109 NPI number — CENTRAL CAROLINA MEDICAL CLINIC, PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL CAROLINA MEDICAL CLINIC, 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:
CENTRAL CAROLINA MEDICAL CLINIC, PA - PAW CREEK CENTER
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:
1407271109
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/04/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6404 ALBEMARLE ROAD
Provider Second Line Business Mailing Address:
SUITE J & K
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-532-8884
Provider Business Mailing Address Fax Number:
704-532-8789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 LITTLE ROCK ROAD
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:
28214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-532-8884
Provider Business Practice Location Address Fax Number:
704-532-8789
Provider Enumeration Date:
03/04/2014

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
TUONG
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
704-532-8884

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  2008-00070 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 2000-00566 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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