=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598411449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMPREHENSIVE PAIN CONSULTANTS OF THE CAROLINAS PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2022
-----------------------------------------------------
Last Update Date | 03/01/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 431 S MAIN ST STE 2
-----------------------------------------------------
City | RUTHERFORDTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28139-2949
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-483-4438
-----------------------------------------------------
Fax | 828-333-5879
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 OVERLOOK RD STE B
-----------------------------------------------------
City | ASHEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28803-3319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING SPECIALIST
-----------------------------------------------------
Name | JULIE ANNE JUSTICE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 828-550-9068
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------