Healthcare Provider Details

I. General information

NPI: 1588693493
Provider Name (Legal Business Name): CHERRYVILLE PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 OAK ST
CHERRYVILLE NC
28021-3423
US

IV. Provider business mailing address

PO BOX 601884
CHARLOTTE NC
28260-1884
US

V. Phone/Fax

Practice location:
  • Phone: 980-487-2200
  • Fax: 704-435-3295
Mailing address:
  • Phone: 980-487-2200
  • Fax: 704-435-3295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L WIENS
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-355-0648