Healthcare Provider Details

I. General information

NPI: 1407271109
Provider Name (Legal Business Name): CENTRAL CAROLINA MEDICAL CLINIC, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2014
Last Update Date: 03/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 LITTLE ROCK ROAD
CHARLOTTE NC
28214
US

IV. Provider business mailing address

6404 ALBEMARLE ROAD SUITE J & K
CHARLOTTE NC
28214
US

V. Phone/Fax

Practice location:
  • Phone: 704-532-8884
  • Fax: 704-532-8789
Mailing address:
  • Phone: 704-532-8884
  • Fax: 704-532-8789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008-00070
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2000-00566
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: TUONG NGUYEN
Title or Position: OWNER/PHYSICIAN
Credential: MD
Phone: 704-532-8884