Healthcare Provider Details

I. General information

NPI: 1073842290
Provider Name (Legal Business Name): CAROLINAS PHYSICIANS NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2009
Last Update Date: 03/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 NORTH VAN LINGLE MUNGO BLVD.
PAGELAND SC
29728-2319
US

IV. Provider business mailing address

PO BOX 601888
CHARLOTTE NC
28260-1888
US

V. Phone/Fax

Practice location:
  • Phone: 843-672-6127
  • Fax: 843-672-5748
Mailing address:
  • Phone: 843-672-6127
  • Fax: 843-672-5748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DANIEL L WIENS
Title or Position: ADMINISTRATOR
Credential:
Phone: 704-355-0648