Healthcare Provider Details

I. General information

NPI: 1306252994
Provider Name (Legal Business Name): CRYSTAL GILES CARTER LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2014
Last Update Date: 07/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 COPPERFIELD BLVD NE
CONCORD NC
28025-2428
US

IV. Provider business mailing address

515 CLANTON RD
CHARLOTTE NC
28217-1309
US

V. Phone/Fax

Practice location:
  • Phone: 704-782-3131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number79734
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: