Healthcare Provider Details

I. General information

NPI: 1902251978
Provider Name (Legal Business Name): CAROLINA FAMILY HEALTHCARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11220 ELM LN SUITE 102
CHARLOTTE NC
28277-0715
US

IV. Provider business mailing address

11220 ELM LN SUITE 102
CHARLOTTE NC
28277-0715
US

V. Phone/Fax

Practice location:
  • Phone: 704-847-4000
  • Fax: 704-847-4001
Mailing address:
  • Phone: 704-847-4000
  • Fax: 704-847-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0002X
TaxonomyClinic Pharmacy
License Number03735
License Number StateNC

VIII. Authorized Official

Name: DR. DINO KANELOS
Title or Position: PRESIDENT
Credential: MD
Phone: 704-847-4000