Healthcare Provider Details

I. General information

NPI: 1922278241
Provider Name (Legal Business Name): METROLINA PAIN CLINIC DISPENSARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/03/2008
Last Update Date: 05/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6300 E INDEPENDENCE BLVD. SUITE B
CHARLOTTE NC
28212
US

IV. Provider business mailing address

PO BOX 4688
FORT LAUDERDALE FL
33338-4688
US

V. Phone/Fax

Practice location:
  • Phone: 704-568-9133
  • Fax:
Mailing address:
  • Phone: 954-376-7313
  • Fax: 954-697-0153

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number13919
License Number StateNC

VIII. Authorized Official

Name: MS. CICELY EASON
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 954-935-6063