Healthcare Provider Details

I. General information

NPI: 1972680080
Provider Name (Legal Business Name): CAROLINA EXPRESS CARE SELMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 S RAIFORD ST
SELMA NC
27576-3155
US

IV. Provider business mailing address

502 MCKNIGHT DR
KNIGHTDALE NC
27545-7050
US

V. Phone/Fax

Practice location:
  • Phone: 919-217-1411
  • Fax: 919-217-3084
Mailing address:
  • Phone: 919-217-1411
  • Fax: 919-217-3084

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number101583
License Number StateNC

VIII. Authorized Official

Name: DALE WHITE
Title or Position: CEO
Credential:
Phone: 919-217-1411