Healthcare Provider Details

I. General information

NPI: 1700965902
Provider Name (Legal Business Name): CAROLINA CLINIC FOR DIGESTIVE DISEASES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1040 X RAY DR STE B
GASTONIA NC
28054-5438
US

IV. Provider business mailing address

1040 X RAY DR STE B
GASTONIA NC
28054-5438
US

V. Phone/Fax

Practice location:
  • Phone: 704-854-9990
  • Fax: 704-854-9045
Mailing address:
  • Phone: 704-854-9990
  • Fax: 704-854-9045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number33956
License Number StateNC

VIII. Authorized Official

Name: WILLIAM CADDICK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-854-9990