Healthcare Provider Details

I. General information

NPI: 1801964002
Provider Name (Legal Business Name): MICHELLE WALSH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 29TH AVENUE DR NE
HICKORY NC
28601-7323
US

IV. Provider business mailing address

1415 29TH AVENUE DR NE
HICKORY NC
28601-7323
US

V. Phone/Fax

Practice location:
  • Phone: 828-855-3445
  • Fax: 828-855-2840
Mailing address:
  • Phone: 828-855-3445
  • Fax: 828-855-2840

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number600604865
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7704649
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: MICHELLE BOLICK WALSH
Title or Position: OWNER
Credential:
Phone: 828-381-1221