Healthcare Provider Details

I. General information

NPI: 1720123862
Provider Name (Legal Business Name): CAROLINA MEDICAL SUPPLY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 SHELBY RD
KINGS MTN NC
28086-8900
US

IV. Provider business mailing address

1802 SHELBY RD
KINGS MTN NC
28086-8900
US

V. Phone/Fax

Practice location:
  • Phone: 704-730-9500
  • Fax: 704-730-9501
Mailing address:
  • Phone: 704-730-9500
  • Fax: 704-730-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BX2000X
TaxonomyOxygen Equipment & Supplies (DME)
License Number
License Number StateNC

VIII. Authorized Official

Name: MR. KENNETH WARE BLACK SR.
Title or Position: OWNER
Credential:
Phone: 704-730-9500