Provider Demographics
NPI:1063446961
Name:SHOCKWAVE SPECIALISTS OF THE CAROLINAS LLC
Entity Type:Organization
Organization Name:SHOCKWAVE SPECIALISTS OF THE CAROLINAS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:M
Authorized Official - Middle Name:FILMORE
Authorized Official - Last Name:HODNETT
Authorized Official - Suffix:
Authorized Official - Credentials:MBA CPA
Authorized Official - Phone:704-897-2031
Mailing Address - Street 1:PO BOX 30428
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28230
Mailing Address - Country:US
Mailing Address - Phone:704-897-1024
Mailing Address - Fax:704-897-2033
Practice Address - Street 1:705 GRIFFITH ST
Practice Address - Street 2:STE 205
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28036
Practice Address - Country:US
Practice Address - Phone:704-897-1024
Practice Address - Fax:704-897-2033
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC00000213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC014GAOtherBCBS