=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437833464
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARNELL DEWAYNE GOINES
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2023
-----------------------------------------------------
Last Update Date | 06/12/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7312 MAITLAND LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-9062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-930-1513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7312 MAITLAND LN
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28215-9062
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-930-1513
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 347C00000X
-----------------------------------------------------
Taxonomy Name | Private Vehicle
-----------------------------------------------------
License Number | 12996518
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------