=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245012335
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BERNADETTE S MYERS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/16/2023
-----------------------------------------------------
Last Update Date | 10/16/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 537 W SUGAR CREEK RD STE 202
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28213-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-910-2141
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12705 WINTER HAZEL RD APT 101
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28278-7739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-777-0378
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 86-2295235
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------