Healthcare Provider Details

I. General information

NPI: 1548571672
Provider Name (Legal Business Name): CPSC CMG LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 02/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2391 COURT DR STE 120
GASTONIA NC
28054-2196
US

IV. Provider business mailing address

2391 COURT DR STE 120
GASTONIA NC
28054-2196
US

V. Phone/Fax

Practice location:
  • Phone: 704-874-0095
  • Fax: 704-866-8680
Mailing address:
  • Phone: 704-874-0095
  • Fax: 704-866-8680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: VALINDA L. RUTLEDGE
Title or Position: PRESIDENT, CEO
Credential:
Phone: 704-834-2133