Healthcare Provider Details

I. General information

NPI: 1033427091
Provider Name (Legal Business Name): CARDINAL CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2010
Last Update Date: 09/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 PURDUE DRIVE SUITE 200
FAYETTEVILLE NC
28303-5510
US

IV. Provider business mailing address

1540 PURDUE DRIVE SUITE 200
FAYETTEVILLE NC
28303-5510
US

V. Phone/Fax

Practice location:
  • Phone: 910-867-8889
  • Fax: 910-401-1024
Mailing address:
  • Phone: 910-867-8889
  • Fax: 910-401-1024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: THEODORE W LANE
Title or Position: MANAGING PARTNER
Credential: PH.D.
Phone: 910-867-8889