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General NPI Number Information
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NPI Number | 1710215959
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Entity Type | Organization
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Legal Business Name | CHARLOTTE PRIMARY SERVICES INC.
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Dates
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Enumeration Date | 11/30/2009
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Last Update Date | 01/05/2010
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Provider Practice Location Address
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Address Line | 1235 EAST BLVD
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City | CHARLOTTE
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State | NC
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Zip | 28203-5870
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Country | US
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Telephone | 252-470-8358
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 85073 # 51164
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City | RICHMOND
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State | VA
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Zip | 23285-5073
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Country | US
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Telephone | 704-763-5948
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. GONZALO OLIVERA
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Credential |
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Telephone | 704-763-5948
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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