Healthcare Provider Details

I. General information

NPI: 1194040642
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2010
Last Update Date: 06/19/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 S MAIN ST
MOUNT HOLLY NC
28120-1620
US

IV. Provider business mailing address

PO BOX 60122
CHARLOTTE NC
28260-0122
US

V. Phone/Fax

Practice location:
  • Phone: 704-822-3605
  • Fax: 704-827-0479
Mailing address:
  • Phone: 704-822-3605
  • Fax: 704-827-0479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

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