Healthcare Provider Details

I. General information

NPI: 1093633737
Provider Name (Legal Business Name): MCPC-19, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 SANDHURST DR
FAYETTEVILLE NC
28304-4426
US

IV. Provider business mailing address

522 SANDHURST DR
FAYETTEVILLE NC
28304-4426
US

V. Phone/Fax

Practice location:
  • Phone: 919-897-2265
  • Fax:
Mailing address:
  • Phone: 919-897-2265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: MICKEY WHELESS FOSTER
Title or Position: CEO
Credential:
Phone: 910-715-4473