Healthcare Provider Details

I. General information

NPI: 1427260108
Provider Name (Legal Business Name): FIRST CARE MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2007
Last Update Date: 04/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7884 IDLEWILD ROAD
INDIANTRAIL NC
28079
US

IV. Provider business mailing address

404 S SUTHERLAND AVE
MONROE NC
28112-5060
US

V. Phone/Fax

Practice location:
  • Phone: 704-291-9267
  • Fax: 704-291-7413
Mailing address:
  • Phone: 704-291-9267
  • Fax: 704-225-0428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE85143
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE85143
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberE85143
License Number StateNC

VIII. Authorized Official

Name: BENEDICT O OKWARA
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 704-291-9267