Healthcare Provider Details

I. General information

NPI: 1922256254
Provider Name (Legal Business Name): NC MEDTECH PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 03/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10620 PARK RD SUITE 102
CHARLOTTE NC
28210-8472
US

IV. Provider business mailing address

10620 PARK RD SUITE 102
CHARLOTTE NC
28210-8472
US

V. Phone/Fax

Practice location:
  • Phone: 305-866-9951
  • Fax: 877-284-8933
Mailing address:
  • Phone: 704-541-7654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77796
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number77796
License Number StateNC

VIII. Authorized Official

Name: DR. BROC LANE PRATT
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-541-7654