Healthcare Provider Details

I. General information

NPI: 1205132677
Provider Name (Legal Business Name): CAROLINA HEALTHCARE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2011
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14057 US HIGHWAY 17 N SUITE 130-B
HAMPSTEAD NC
28443-3770
US

IV. Provider business mailing address

PO BOX 602484
CHARLOTTE NC
28260-2484
US

V. Phone/Fax

Practice location:
  • Phone: 910-270-1637
  • Fax: 910-762-1873
Mailing address:
  • Phone: 910-270-1637
  • Fax: 910-762-1873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL WIENS
Title or Position: SENIOR VICE PRESIDENT OPERATIONS
Credential:
Phone: 704-355-0648