Provider Demographics
NPI:1073575486
Name:EQUISTAT LLC
Entity Type:Organization
Organization Name:EQUISTAT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:LAMAR
Authorized Official - Middle Name:L
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:704-482-1447
Mailing Address - Street 1:1403 N LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3406
Mailing Address - Country:US
Mailing Address - Phone:704-482-1447
Mailing Address - Fax:704-481-9744
Practice Address - Street 1:1403 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3406
Practice Address - Country:US
Practice Address - Phone:704-482-1447
Practice Address - Fax:704-481-9744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2010-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014G5Medicaid
NC2330929Medicare ID - Type Unspecified