Healthcare Provider Details

I. General information

NPI: 1518532126
Provider Name (Legal Business Name): MOUNTCASTLE MEDICAL & MED SPA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S MAIN ST
LILLINGTON NC
27546-7681
US

IV. Provider business mailing address

701 S MAIN ST
LILLINGTON NC
27546-7681
US

V. Phone/Fax

Practice location:
  • Phone: 910-984-1152
  • Fax: 910-984-1171
Mailing address:
  • Phone: 910-984-1152
  • Fax: 910-984-1171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: BRANDY N MOUNTCASTLE
Title or Position: MEMBER, ORGANIZER, OWNER, CEO, PA-C
Credential: PA-C
Phone: 910-890-6590