Healthcare Provider Details

I. General information

NPI: 1184305294
Provider Name (Legal Business Name): MAINSTREET AND KIDSSTREET OF NORTH CAROLINA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 US HWY 70 WEST
HAVELOCK NC
28532
US

IV. Provider business mailing address

1500 1ST AVE N UNIT 3
BIRMINGHAM AL
35203-1866
US

V. Phone/Fax

Practice location:
  • Phone: 252-652-2046
  • Fax: 252-294-1210
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANDREW SMITH
Title or Position: VP
Credential:
Phone: 205-545-5085