Healthcare Provider Details

I. General information

NPI: 1538143375
Provider Name (Legal Business Name): MEDEMPORIUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CROSSBEAM DR
CHARLOTTE NC
28217-2800
US

IV. Provider business mailing address

1300 CROSSBEAM DR
CHARLOTTE NC
28217-2800
US

V. Phone/Fax

Practice location:
  • Phone: 704-535-2201
  • Fax: 704-535-3836
Mailing address:
  • Phone: 704-535-2201
  • Fax: 704-535-3836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number00358
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number00358
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number7135
License Number StateNC

VIII. Authorized Official

Name: MARYANN BISHOP LARGEN
Title or Position: CHIEF OPERATING OFFICER
Credential: R.PH.
Phone: 704-535-2201