Healthcare Provider Details

I. General information

NPI: 1124946652
Provider Name (Legal Business Name): ENDOLASTIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2026
Last Update Date: 07/10/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8817 WESTGATE PZRK DR. STE 110
RALEIGH NC
27617
US

IV. Provider business mailing address

8817 WESTGATE PZRK DR. STE 110
RALEIGH NC
27617
US

V. Phone/Fax

Practice location:
  • Phone: 336-712-6427
  • Fax:
Mailing address:
  • Phone: 336-712-6427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: FREDERICK HALLER
Title or Position: CEO
Credential:
Phone: 336-712-6427