Healthcare Provider Details

I. General information

NPI: 1407104466
Provider Name (Legal Business Name): CAROLINAS HEALTHCARE ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/24/2012
Last Update Date: 01/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 MEMORIAL DR
JACKSONVILLE NC
28546-6333
US

IV. Provider business mailing address

PO BOX 602484
CHARLOTTE NC
28260-2484
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-9994
  • Fax: 910-353-5784
Mailing address:
  • Phone: 910-353-9994
  • Fax: 910-353-5784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088F0040X
TaxonomyUrogynecology and Reconstructive Pelvic Surgery (Urology) Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAN E GOODWIN
Title or Position: VP
Credential:
Phone: 910-667-7597