=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518136068
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDIAC WELLNESS SPECIALISTS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2008
-----------------------------------------------------
Last Update Date | 02/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 S MCCASKEY RD
-----------------------------------------------------
City | WILLIAMSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27892-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-792-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 S MCCASKEY RD
-----------------------------------------------------
City | WILLIAMSTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27892-2150
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-792-0100
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. LILLIAN H. DUNLOW
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 252-792-0100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | 9700775
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------