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General NPI Number Information
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NPI Number | 1831615160
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Entity Type | Organization
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Legal Business Name | SOUTHEAST FAMILY CARE PLLC
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Dates
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Enumeration Date | 08/18/2017
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Last Update Date | 08/18/2017
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Provider Practice Location Address
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Address Line | 10035 PARK CEDAR DR STE 100
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City | CHARLOTTE
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State | NC
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Zip | 28210-8910
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Country | US
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Telephone | 704-544-2524
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Fax | 704-544-2647
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Provider Business Mailing Address
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Address Line | 3041 DANIEL PLACE DR
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City | CHARLOTTE
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State | NC
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Zip | 28213
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Country | US
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Telephone | 704-544-2524
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Fax | 704-544-2647
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Authorized Official
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Title or Position | PRESIDENT/PHYSICIAN
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Name | MR. HIRENKUMAR D ITALIA
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Credential | MD
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Telephone | 704-512-9921
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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 | 2013-01926
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License Number State | NC
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