Provider Demographics
NPI:1073842290
Name:CAROLINAS PHYSICIANS NETWORK INC
Entity Type:Organization
Organization Name:CAROLINAS PHYSICIANS NETWORK INC
Other - Org Name:PAGELAND FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 601888
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1888
Mailing Address - Country:US
Mailing Address - Phone:843-672-6127
Mailing Address - Fax:843-672-5748
Practice Address - Street 1:301 NORTH VAN LINGLE MUNGO BLVD.
Practice Address - Street 2:
Practice Address - City:PAGELAND
Practice Address - State:SC
Practice Address - Zip Code:29728-2319
Practice Address - Country:US
Practice Address - Phone:843-672-6127
Practice Address - Fax:843-672-5748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-17
Last Update Date:2015-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC42-3846OtherRURAL HEALTH CLINIC