MEDICARE: CAROLINA CENTER FOR RESTORATIVE MEDICINE

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	2083P0500X	Preventive Medicine/Occupational Environmental Medicine Physician	36330	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	23469	OTHER	NC	BCBS

General Provider Information

NPI Number	:	1659815140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAROLINA CENTER FOR RESTORATIVE MEDICINE

Provider Business Mailing Address
First Line	:	809 SPRING FOREST RD
Second Line	:	SUITE 100
City	:	RALEIGH
State	:	NC
Zip	:	27609-9700
Country	:	US
Telephone Number	:	919-803-4268
Fax Number	:	919-977-1381

Provider Business Practice Location Address
First Line	:	809 SPRING FOREST RD
Second Line	:	SUITE 100
City	:	RALEIGH
State	:	NC
Zip	:	27609-9198
Country	:	US
Telephone Number	:	919-803-4268
Fax Number	:	919-977-1381

Authorized Official
Title or Position	:	PRACTICE MANAGER
Name	:	MISS STEPHENIA BENITA JEFFRIES
Credential	:
Telephone Number	:	919-803-4268

Provider Enumeration Date	:	12/19/2016
Last Update Date	:	12/19/2016

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