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General NPI Number Information
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NPI Number | 1336155951
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Entity Type | Organization
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Legal Business Name | PROVIDENCE MEDICAL CLINIC, INC.
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Dates
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Enumeration Date | 08/01/2006
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Last Update Date | 02/01/2010
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Provider Practice Location Address
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Address Line | 271 NE EXECUTIVE PARK DRIVE
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City | CONCORD
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State | NC
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Zip | 28025
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Country | US
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Telephone | 704-721-4232
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Fax | 704-721-4240
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Provider Business Mailing Address
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Address Line | 271 NE EXECUTIVE PARK DRIVE
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City | CONCORD
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State | NC
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Zip | 28025
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Country | US
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Telephone | 704-721-4232
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Fax | 704-721-4240
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. ADEBOLA K. ADEKANMBI
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Credential | M.D.
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Telephone | 704-721-4232
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 9900744
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | NC9900744
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License Number State | NC
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