Healthcare Provider Details

I. General information

NPI: 1053642363
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2010
Last Update Date: 01/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5435 PROSPERITY CHURCH ROAD STE 2200
CHARLOTTE NC
28269-2344
US

IV. Provider business mailing address

PO BOX 602120
CHARLOTTE NC
28260-2120
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-9830
  • Fax: 704-863-9831
Mailing address:
  • Phone: 704-512-4808
  • Fax: 704-512-4838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. THOMAS FORD LAYMON
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-446-8250