=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013304211
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EAGLE RISING HEALTH SERVICES, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/25/2015
-----------------------------------------------------
Last Update Date | 04/25/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8815 UNIVERSITY EAST DR STE 215
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28213-4100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-318-3602
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1008 CHARLES AVE
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28205-1535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-334-6370
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. WAYNE JEROME HARP JR.
-----------------------------------------------------
Credential | P.A.
-----------------------------------------------------
Telephone | 704-334-6370
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QH0100X
-----------------------------------------------------
Taxonomy Name | Health Service Clinic/Center
-----------------------------------------------------
License Number | 101599
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 101599
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------