Healthcare Provider Details

I. General information

NPI: 1063403160
Provider Name (Legal Business Name): CHARLENE LYDIA BLAINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11048 CLEVELAND ROAD SUITE 101-102
GARNER NC
27529
US

IV. Provider business mailing address

11048 CLEVELAND ROAD SUITE 101-102
GARNER NC
27529
US

V. Phone/Fax

Practice location:
  • Phone: 919-359-9920
  • Fax: 919-359-2520
Mailing address:
  • Phone: 919-359-9920
  • Fax: 919-359-2520

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number9500533
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number9500533
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2278P1004X
TaxonomyPulmonary Diagnostics Certified Respiratory Therapist
License NumberA-4125
License Number StateNC

VIII. Authorized Official

Name: MRS. CHARLENE LYDIA BLAINE
Title or Position: PRESIDENT
Credential: CRT, RCP
Phone: 919-359-9920