Provider Demographics
NPI:1235982901
Name:ST PANTALEON FOUNDATION
Entity Type:Organization
Organization Name:ST PANTALEON FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PERRY
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-288-3961
Mailing Address - Street 1:PO BOX 2062
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-2062
Mailing Address - Country:US
Mailing Address - Phone:980-333-5368
Mailing Address - Fax:888-869-8634
Practice Address - Street 1:4001 OLIVE BRANCH RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8858
Practice Address - Country:US
Practice Address - Phone:980-333-5368
Practice Address - Fax:888-869-8634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-10
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable