Provider Demographics
NPI:1093795155
Name:CLECO PRIMARY CARE NETWORK
Entity Type:Organization
Organization Name:CLECO PRIMARY CARE NETWORK
Other - Org Name:KINGS MOUNTAIN MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FINANCIAL MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:HOYLE
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-480-1087
Mailing Address - Street 1:808 SCHENCK ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:NC
Mailing Address - Zip Code:28150-3934
Mailing Address - Country:US
Mailing Address - Phone:704-480-1087
Mailing Address - Fax:704-484-3260
Practice Address - Street 1:812 WEST KING STREET
Practice Address - Street 2:
Practice Address - City:KINGS MOUNTAIN
Practice Address - State:NC
Practice Address - Zip Code:28086
Practice Address - Country:US
Practice Address - Phone:704-480-9344
Practice Address - Fax:704-739-5271
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CLECO PRIMARY CARE NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-17
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC343963AMedicaid
NC343963CMedicaid
NC343963AMedicaid
NC343963Medicare Oscar/Certification