Healthcare Provider Details

I. General information

NPI: 1043970312
Provider Name (Legal Business Name): CARLOS SURRATT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2021
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 E DIXON BLVD
SHELBY NC
28152-6742
US

IV. Provider business mailing address

122 E DIXON BLVD
SHELBY NC
28152-6742
US

V. Phone/Fax

Practice location:
  • Phone: 803-849-2925
  • Fax:
Mailing address:
  • Phone: 803-849-2925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code347E00000X
TaxonomyTransportation Broker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: