Healthcare Provider Details

I. General information

NPI: 1952535122
Provider Name (Legal Business Name): K MARIO MCNEILL CRT, MMBT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2135 VALLEYGATE DR SUITE 101
FAYETTEVILLE NC
28304-3750
US

IV. Provider business mailing address

280 HILLS LN
ERWIN NC
28339-8412
US

V. Phone/Fax

Practice location:
  • Phone: 910-323-2247
  • Fax: 910-486-8064
Mailing address:
  • Phone: 919-418-6686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code246ZE0500X
TaxonomyEEG Specialist/Technologist
License Number
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: