Healthcare Provider Details

I. General information

NPI: 1598101974
Provider Name (Legal Business Name): CAROLINA PAIN AND WEIGHT LOSS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 WELTON WAY
MOORESVILLE NC
28117-9163
US

IV. Provider business mailing address

131 WELTON WAY
MOORESVILLE NC
28117-9163
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-4564
  • Fax: 704-360-4553
Mailing address:
  • Phone: 704-360-4564
  • Fax: 704-360-4553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number201516
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. CAROLYN D DAVIS
Title or Position: PRESIDENT
Credential: FNP
Phone: 704-360-4564