=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679937205
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WELLNESS OF NORTH CAROLINA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2016
-----------------------------------------------------
Last Update Date | 04/10/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13521 STEELECROFT PKWY STE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28278-7889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-729-7578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13521 STEELECROFT PKWY STE B
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28278-7889
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 646-729-7578
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/CEO
-----------------------------------------------------
Name | THOMAS JOSEPH MULLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 646-729-7578
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 31845
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------