MEDICARE: FAYETTEVILLE ALLSTAR WHEELCHAIR SPORTS TEAM

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	251V00000X	Voluntary or Charitable Agency

General Provider Information

NPI Number	:	1548686967
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FAYETTEVILLE ALLSTAR WHEELCHAIR SPORTS TEAM

Provider Business Mailing Address
First Line	:	PO BOX 3066
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28302-3066
Country	:	US
Telephone Number	:	910-273-3278
Fax Number	:

Provider Business Practice Location Address
First Line	:	425 BRISTLECONE RD
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28311-7698
Country	:	US
Telephone Number	:	910-273-3278
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MRS. ROCHELLE MYLES MCCLAIN
Credential	:
Telephone Number	:	910-273-3278

Provider Enumeration Date	:	03/10/2014
Last Update Date	:	03/10/2014

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