Healthcare Provider Details

I. General information

NPI: 1376013243
Provider Name (Legal Business Name): MISSION HEALTH COMMUNITY MULTISPECIALTY PROVIDERS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 05/15/2020
Certification Date: 05/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 VANDERBILT PARK DR
ASHEVILLE NC
28803-1700
US

IV. Provider business mailing address

PO BOX 603366
CHARLOTTE NC
28260-3366
US

V. Phone/Fax

Practice location:
  • Phone: 828-213-1740
  • Fax:
Mailing address:
  • Phone: 828-213-1500
  • Fax: 828-681-1575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: TEDRICK JOHNSON
Title or Position: GROUP VICE PRESIDENT
Credential:
Phone: 615-372-3755