Healthcare Provider Details

I. General information

NPI: 1013142488
Provider Name (Legal Business Name): CAROLINA ANTI-AGING & WELLNESS CENTER PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2009
Last Update Date: 05/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1227 CARTHAGE ST
SANFORD NC
27330-8984
US

IV. Provider business mailing address

1227 CARTHAGE ST
SANFORD NC
27330-8984
US

V. Phone/Fax

Practice location:
  • Phone: 919-774-0502
  • Fax: 919-774-0505
Mailing address:
  • Phone: 919-774-0502
  • Fax: 919-774-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number39413
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number39413
License Number StateNC

VIII. Authorized Official

Name: SUSAN WATSON DURHAM
Title or Position: PRESIDENT
Credential: MD
Phone: 919-774-0502