Healthcare Provider Details

I. General information

NPI: 1316298045
Provider Name (Legal Business Name): BROADVIEW HEALTH, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2012
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17232 LANCASTER HWY
CHARLOTTE NC
28277-2002
US

IV. Provider business mailing address

349 VENUS ST
MONROE NC
28112-4025
US

V. Phone/Fax

Practice location:
  • Phone: 704-544-0050
  • Fax: 704-544-0050
Mailing address:
  • Phone: 704-635-7418
  • Fax: 704-635-7500

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number2009-00832
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier5921569
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer
# 2
Identifier1083043913
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: KAREN TREASURE
Title or Position: PROVIDER
Credential: NP
Phone: 704-544-0050