Healthcare Provider Details

I. General information

NPI: 1699760702
Provider Name (Legal Business Name): ENT CAROLINA PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2005
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 ABERDEEN BLVD
GASTONIA NC
28054-0635
US

IV. Provider business mailing address

2520 ABERDEEN BLVD
GASTONIA NC
28054-0635
US

V. Phone/Fax

Practice location:
  • Phone: 704-868-8400
  • Fax: 704-868-8493
Mailing address:
  • Phone: 704-868-8400
  • Fax: 704-868-8493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MRS. JANE A BYRUM
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 704-868-8400