Healthcare Provider Details

I. General information

NPI: 1740755610
Provider Name (Legal Business Name): SOUTH LAKE PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2018
Last Update Date: 07/16/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 FORNEY CREEK PKWY STE 2100
DENVER NC
28037-9514
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-801-3097
  • Fax:
Mailing address:
  • Phone: 704-631-0002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS LAYMON
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-446-8250