Healthcare Provider Details

I. General information

NPI: 1982918314
Provider Name (Legal Business Name): FAMILY MEDICINE CARE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 09/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18509 STATESVILLE RD STE B1
CORNELIUS NC
28031-5703
US

IV. Provider business mailing address

18509 STATESVILLE RD STE B1
CORNELIUS NC
28031-5703
US

V. Phone/Fax

Practice location:
  • Phone: 704-359-7426
  • Fax:
Mailing address:
  • Phone: 704-359-7426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number201000567
License Number StateNC

VIII. Authorized Official

Name: DR. MARIO AUGUSTO HERNANDEZ
Title or Position: MD
Credential: MD
Phone: 704-359-7426