Healthcare Provider Details

I. General information

NPI: 1366677692
Provider Name (Legal Business Name): 4C COMPANY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2009
Last Update Date: 09/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3505 ORIOLE PL
CHARLOTTE NC
28269-1214
US

IV. Provider business mailing address

3552 BEATTIES FORD ROAD
CHARLOTTE NC
28216-3742
US

V. Phone/Fax

Practice location:
  • Phone: 704-394-8968
  • Fax: 704-394-8967
Mailing address:
  • Phone: 704-394-8968
  • Fax: 704-394-8967

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberFCL-060-115
License Number StateNC

VIII. Authorized Official

Name: MRS. LISA WIGFALL
Title or Position: CEO
Credential: MSW
Phone: 704-394-8968