Provider Demographics
NPI:1215377387
Name:CAROLINA ANTI-AGING AND NEUROPATHY, PLLC
Entity Type:Organization
Organization Name:CAROLINA ANTI-AGING AND NEUROPATHY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:704-822-5433
Mailing Address - Street 1:7476 WATERSIDE LOOP RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:DENVER
Mailing Address - State:NC
Mailing Address - Zip Code:28037-7679
Mailing Address - Country:US
Mailing Address - Phone:704-822-5433
Mailing Address - Fax:704-822-5997
Practice Address - Street 1:7476 WATERSIDE LOOP RD
Practice Address - Street 2:SUITE 600
Practice Address - City:DENVER
Practice Address - State:NC
Practice Address - Zip Code:28037-7679
Practice Address - Country:US
Practice Address - Phone:704-822-5433
Practice Address - Fax:704-822-5997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC190034261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty