MEDICARE: MEDICAL ASSESSMENT CLINIC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	3547	NC

General Provider Information

NPI Number	:	1548511595
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL ASSESSMENT CLINIC

Provider Business Mailing Address
First Line	:	4912 ALBEMARLE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6618
Country	:	US
Telephone Number	:	980-229-3722
Fax Number	:	704-896-8193

Provider Business Practice Location Address
First Line	:	4912 ALBEMARLE RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28205-6618
Country	:	US
Telephone Number	:	980-229-3722
Fax Number	:	704-896-8193

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. LAN LE BONNO LEBOZEC
Credential	:
Telephone Number	:	980-229-3722

Provider Enumeration Date	:	09/29/2012
Last Update Date	:	09/29/2012

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