1760512032 NPI number — AZALEA SKIN TREATMENT CENTER PA

Table of content: (NPI 1760512032)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760512032 NPI number — AZALEA SKIN TREATMENT CENTER PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AZALEA SKIN TREATMENT CENTER 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:
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:
1760512032
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60634
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:
28260-0634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-772-3487
Provider Business Mailing Address Fax Number:
919-772-3446

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
958 VANDORA SPRINGS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GARNER
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27529-3544
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-772-3487
Provider Business Practice Location Address Fax Number:
919-772-3446
Provider Enumeration Date:
03/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KETCHAM
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
STEWART
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
919-773-4959

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  29605 , 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: 0273L . This is a "BCBS OF NC GROUP NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 070014474 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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