=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285936021
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TRUECARE FAMILY MEDICINE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2010
-----------------------------------------------------
Last Update Date | 01/25/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4936 SARAH HALL LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28270-0295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-916-9895
-----------------------------------------------------
Fax | 888-419-0818
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4936 SARAH HALL LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28270-0295
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-916-9895
-----------------------------------------------------
Fax | 888-419-0818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JACK PAUL SHEPHERD III
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-916-9895
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 200201174
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------