=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851616353
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAROLINAS PHYSICIANS NETWORK INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/29/2010
-----------------------------------------------------
Last Update Date | 06/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3431 MORGANTON BLVD SW
-----------------------------------------------------
City | LENOIR
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28645-8628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-373-0212
-----------------------------------------------------
Fax | 704-342-5871
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 601067
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28260-1067
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-373-0212
-----------------------------------------------------
Fax | 704-342-5871
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SVP
-----------------------------------------------------
Name | DANIEL L WIENS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-355-0648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0202X
-----------------------------------------------------
Taxonomy Name | Pediatric Cardiology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------