Healthcare Provider Details

I. General information

NPI: 1669807533
Provider Name (Legal Business Name): PULSE SPORTZ FOUNDATION INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 FRIENDLY PL
CHARLOTTE NC
28213-5800
US

IV. Provider business mailing address

818 FRIENDLY PL
CHARLOTTE NC
28213-5800
US

V. Phone/Fax

Practice location:
  • Phone: 704-496-0501
  • Fax:
Mailing address:
  • Phone: 704-496-0501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 6
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: RYAN SMITH
Title or Position: PRES.
Credential:
Phone: 704-496-0501