Healthcare Provider Details

I. General information

NPI: 1427015254
Provider Name (Legal Business Name): LAKE NORMAN PEDIATRICS, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

656 CARPENTER AVE
MOORESVILLE NC
28115-2538
US

IV. Provider business mailing address

656 CARPENTER AVE
MOORESVILLE NC
28115-2538
US

V. Phone/Fax

Practice location:
  • Phone: 704-664-1297
  • Fax: 704-799-6356
Mailing address:
  • Phone: 704-664-1297
  • Fax: 704-799-6356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIM M CAVIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 704-664-1297