=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922256254
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NC MEDTECH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2008
-----------------------------------------------------
Last Update Date | 03/11/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10620 PARK RD SUITE 102
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-8472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-866-9951
-----------------------------------------------------
Fax | 877-284-8933
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10620 PARK RD SUITE 102
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-8472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-541-7654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BROC LANE PRATT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 704-541-7654
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 77796
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 77796
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------