1407883929 NPI number — CAPITAL CARE RESOURCES, LLC

Table of content: DR. ROBERT WESLIE TYSON MD (NPI 1629047477)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407883929 NPI number — CAPITAL CARE RESOURCES, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITAL CARE RESOURCES, LLC
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:
6
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:
1407883929
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6330 SPRINT PKWY STE 300
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OVERLAND PARK
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66211-1157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11111 CARMEL COMMONS BLVD.
Provider Second Line Business Practice Location Address:
SUITE 350-B
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28226-5319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-598-2716
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
AUTHORIZED SIGNATORY
Authorized Official Telephone Number:
913-814-2077

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3427196 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 007AE . This is a "G2" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1407883929 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 62-1633405 . This is a "G2" identifier . This identifiers is of the category "OTHER".




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