Healthcare Provider Details

I. General information

NPI: 1073540365
Provider Name (Legal Business Name): UNION FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 REYNOLDS STREET SUITE 100
MONROE NC
28112-4376
US

IV. Provider business mailing address

PO BOX 601888
CHARLOTTE NC
28260-1888
US

V. Phone/Fax

Practice location:
  • Phone: 704-289-5443
  • Fax: 704-283-7655
Mailing address:
  • Phone: 704-289-5443
  • Fax: 704-283-7655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L WIENS
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-355-0648