Provider Demographics
NPI:1033427091
Name:CARDINAL CLINIC, LLC
Entity Type:Organization
Organization Name:CARDINAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:W
Authorized Official - Last Name:LANE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:910-867-8889
Mailing Address - Street 1:1540 PURDUE DRIVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5510
Mailing Address - Country:US
Mailing Address - Phone:910-867-8889
Mailing Address - Fax:910-401-1024
Practice Address - Street 1:1540 PURDUE DRIVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5510
Practice Address - Country:US
Practice Address - Phone:910-867-8889
Practice Address - Fax:910-401-1024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-23
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251B00000XAgenciesCase Management
No253J00000XAgenciesFoster Care Agency