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General NPI Number Information
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NPI Number | 1083729701
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Entity Type | Organization
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Legal Business Name | NORTHLAKE PEDIATRIC CARE PA
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Dates
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Enumeration Date | 08/20/2006
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Last Update Date | 05/30/2013
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Provider Practice Location Address
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Address Line | 2117 SIMONTON RD SUITE 402
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City | STATESVILLE
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State | NC
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Zip | 28625-8206
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Country | US
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Telephone | 704-871-2323
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Fax | 803-619-2149
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Provider Business Mailing Address
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Address Line | 2117 SIMONTON RD SUITE 402
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City | STATESVILLE
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State | NC
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Zip | 28625-8206
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Country | US
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Telephone | 704-871-2323
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Fax | 803-619-2149
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL BORJA
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Credential | MD
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Telephone | 704-871-2323
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number |
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License Number State |
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