=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972905644
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CALVARY COMMUNITY MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2014
-----------------------------------------------------
Last Update Date | 09/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 537 W SUGAR CREEK RD SUITE 201
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28213-6102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-979-8210
-----------------------------------------------------
Fax | 187-749-2888
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16725 WINSTON OAKS CT
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28213-5206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-534-1035
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | OKYERE BONNA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 704-526-9052
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number | 5007063
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------