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General NPI Number Information
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NPI Number | 1215165659
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Entity Type | Organization
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Legal Business Name | MARIETTA MEDICAL CLINIC PA
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Dates
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Enumeration Date | 06/24/2009
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Last Update Date | 06/24/2009
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Provider Practice Location Address
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Address Line | 401 S MARIETTA ST
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City | GASTONIA
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State | NC
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Zip | 28052-4331
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Country | US
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Telephone | 704-866-8030
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Fax | 704-866-8717
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Provider Business Mailing Address
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Address Line | 401 S MARIETTA ST
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City | GASTONIA
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State | NC
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Zip | 28052-4331
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Country | US
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Telephone | 704-866-8030
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Fax | 704-866-8717
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. CHARLES K AGUNOBI
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Credential | MD
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Telephone | 704-866-8030
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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