Healthcare Provider Details

I. General information

NPI: 1952337289
Provider Name (Legal Business Name): SHELBY CHILDREN'S CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 N DEKALB ST
SHELBY NC
28150-3911
US

IV. Provider business mailing address

5000 AIRPORT CENTER PKWY STE A
CHARLOTTE NC
28208-5899
US

V. Phone/Fax

Practice location:
  • Phone: 704-482-1435
  • Fax: 704-482-8779
Mailing address:
  • Phone: 704-512-4116
  • Fax: 704-371-7284

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL L WIENS
Title or Position: SENIOR VICE PRESIDENT
Credential:
Phone: 704-355-0648