MEDICARE: CHARLOTTE PRIMARY SERVICES INC.

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1710215959
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHARLOTTE PRIMARY SERVICES INC.

Provider Business Mailing Address
First Line	:	PO BOX 85073
Second Line	:	# 51164
City	:	RICHMOND
State	:	VA
Zip	:	23285-5073
Country	:	US
Telephone Number	:	704-763-5948
Fax Number	:

Provider Business Practice Location Address
First Line	:	1235 EAST BLVD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28203-5870
Country	:	US
Telephone Number	:	252-470-8358
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. GONZALO OLIVERA
Credential	:
Telephone Number	:	704-763-5948

Provider Enumeration Date	:	11/30/2009
Last Update Date	:	01/05/2010

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