1063446961 NPI number — SHOCKWAVE SPECIALISTS OF THE CAROLINAS LLC

Table of content: (NPI 1063446961)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063446961 NPI number — SHOCKWAVE SPECIALISTS OF THE CAROLINAS LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHOCKWAVE SPECIALISTS OF THE CAROLINAS 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:
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:
1063446961
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 30428
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:
28230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-897-1024
Provider Business Mailing Address Fax Number:
704-897-2033

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
705 GRIFFITH ST
Provider Second Line Business Practice Location Address:
STE 205
Provider Business Practice Location Address City Name:
DAVIDSON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28036
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-897-1024
Provider Business Practice Location Address Fax Number:
704-897-2033
Provider Enumeration Date:
07/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HODNETT
Authorized Official First Name:
M
Authorized Official Middle Name:
FILMORE
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
704-897-2031

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  00000 , 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: 014GA . This is a "BCBS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com