Healthcare Provider Details

I. General information

NPI: 1487091013
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2013
Last Update Date: 01/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5651 POPLAR TENT RD SUITE 200
CONCORD NC
28027-7530
US

IV. Provider business mailing address

PO BOX 602148
CHARLOTTE NC
28260-2148
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-4878
  • Fax:
Mailing address:
  • Phone: 704-863-4878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L WIENS
Title or Position: SVP/OPERATIONS
Credential:
Phone: 704-355-0648