1710056742 NPI number — BELLFLOWER LANE

Table of content: (NPI 1710056742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710056742 NPI number — BELLFLOWER LANE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BELLFLOWER LANE
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:
1710056742
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 480794
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28269-5323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-566-6134
Provider Business Mailing Address Fax Number:
704-566-6136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3124 MILTON RD
Provider Second Line Business Practice Location Address:
SUITE 231
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28215-5008
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-566-6134
Provider Business Practice Location Address Fax Number:
704-566-6136
Provider Enumeration Date:
11/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HENRY
Authorized Official First Name:
CLARISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR BUSINESS DEVELOPMENT
Authorized Official Telephone Number:
704-566-6134

Provider Taxonomy Codes

  • Taxonomy code: 322D00000X , with the licence number:  MHL-060-575 , 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)

  • Identifier: 6603949 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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