1669664264 NPI number — MOUNTAIN ISLAND FAMILY MEDICINE, PC

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 1669664264 NPI number — MOUNTAIN ISLAND FAMILY MEDICINE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOUNTAIN ISLAND FAMILY MEDICINE, PC
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:
1669664264
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10226 COULOAK DR
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28216-7675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-399-1415
Provider Business Mailing Address Fax Number:
704-399-1415

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10226 COULOAK DR
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28216-7675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-399-1415
Provider Business Practice Location Address Fax Number:
704-399-1415
Provider Enumeration Date:
08/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
CLAYTON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
704-399-1415

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  125435 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2026 www.npivalidator.com