=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780077099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINAS PHYSICIANS NETWORK, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/11/2015
-----------------------------------------------------
Last Update Date | 08/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 420 PARK ST SUITE 105A
-----------------------------------------------------
City | BELMONT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28012-3393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-631-1820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 602148
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-2148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-631-1820
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP
-----------------------------------------------------
Name | MISS THOMAS FORD LAYMON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-631-0002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------