Healthcare Provider Details

I. General information

NPI: 1003067695
Provider Name (Legal Business Name): JEFF RANDALL MISHOE D.MIN.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2008
Last Update Date: 10/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 EAST BLVD C-8
CHARLOTTE NC
28203-4891
US

IV. Provider business mailing address

310 EAST BLVD C-8
CHARLOTTE NC
28203-4891
US

V. Phone/Fax

Practice location:
  • Phone: 704-344-1100
  • Fax: 704-344-1100
Mailing address:
  • Phone: 704-344-1100
  • Fax: 704-344-1100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number15
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: