Healthcare Provider Details

I. General information

NPI: 1417446667
Provider Name (Legal Business Name): CAROLINA MEDICORP ENTERPRISES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BILLINGSLEY RD STE 101
CHARLOTTE NC
28211-5020
US

IV. Provider business mailing address

PO BOX 751803
CHARLOTTE NC
28275-1803
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-7605
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License Number
License Number StateNC

VIII. Authorized Official

Name: SHALA DAVIS
Title or Position: RCS MANAGER
Credential:
Phone: 704-316-7845