Provider Demographics
NPI:1073268702
Name:LAO, TIM (CSCS)
Entity Type:Individual
Prefix:
First Name:TIM
Middle Name:
Last Name:LAO
Suffix:
Gender:M
Credentials:CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4651 CHARLOTTE PARK DR STE 300
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-1916
Mailing Address - Country:US
Mailing Address - Phone:704-529-6161
Mailing Address - Fax:
Practice Address - Street 1:4651 CHARLOTTE PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-1916
Practice Address - Country:US
Practice Address - Phone:704-529-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA200217169405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional