=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902298839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FRYECARE NORTHWEST HICKORY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2015
-----------------------------------------------------
Last Update Date | 06/07/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 TATE BLVD SE STE 186
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28602-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-449-8458
-----------------------------------------------------
Fax | 828-323-8348
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 915 TATE BLVD SE STE 186
-----------------------------------------------------
City | HICKORY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28602-4042
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-449-8458
-----------------------------------------------------
Fax | 828-323-8348
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | REGIONAL CFO, TENET
-----------------------------------------------------
Name | MR. WESLEY O. JAMES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-265-5009
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC1900X
-----------------------------------------------------
Taxonomy Name | Counseling Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------