=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366738361
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAYSTONE FAMILY HEALTHCARE-TENET NORTH CAROLINA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/28/2011
-----------------------------------------------------
Last Update Date | 06/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3511 GRAYSTONE PL SE
-----------------------------------------------------
City | CONOVER
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28613-8201
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-326-9355
-----------------------------------------------------
Fax | 828-326-9868
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 741610
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-1610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-326-9355
-----------------------------------------------------
Fax | 828-326-9868
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL CFO, TENET
-----------------------------------------------------
Name | WESLEY O. JAMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-265-5009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------