Provider Demographics
NPI:1235347378
Name:NORTHLAKE CHILDREN'S ASSOCIATES, P.A.
Entity Type:Organization
Organization Name:NORTHLAKE CHILDREN'S ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE/CLINICAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BRITTANY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCHIPPER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:704-663-5240
Mailing Address - Street 1:170A MEDICAL PARK RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117
Mailing Address - Country:US
Mailing Address - Phone:704-663-5240
Mailing Address - Fax:704-663-5399
Practice Address - Street 1:170A MEDICAL PARK RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117
Practice Address - Country:US
Practice Address - Phone:704-663-5240
Practice Address - Fax:704-663-5399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-21
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89011NTMedicaid