Healthcare Provider Details

I. General information

NPI: 1306753983
Provider Name (Legal Business Name): MCPC-30, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 PAGE RD N
PINEHURST NC
28374-4607
US

IV. Provider business mailing address

135 PAGE RD N
PINEHURST NC
28374-4607
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-5134
  • Fax:
Mailing address:
  • Phone: 910-715-5134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: MICKEY SELECT ONE FOSTER
Title or Position: CEO
Credential:
Phone: 910-715-4473