Healthcare Provider Details

I. General information

NPI: 1225576242
Provider Name (Legal Business Name): NICOLE GRAHAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 W INNES ST
SALISBURY NC
28144-2574
US

IV. Provider business mailing address

1401 W INNES ST
SALISBURY NC
28144-2574
US

V. Phone/Fax

Practice location:
  • Phone: 704-636-5626
  • Fax: 704-636-5641
Mailing address:
  • Phone: 704-636-5626
  • Fax: 704-636-5641

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number0010-07063
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0010-07063
License Number StateNC

VIII. Authorized Official

Name: CHETAN AMIN
Title or Position: OFFICE MANAGER/OWNER
Credential: D.O.
Phone: 704-636-5626