Provider Demographics
NPI:1316400088
Name:UNITED PRIMARY DIAGNOSTIC CENTER
Entity Type:Organization
Organization Name:UNITED PRIMARY DIAGNOSTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ENASHA
Authorized Official - Middle Name:L
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-237-4768
Mailing Address - Street 1:2103 N GRAHAM ST STE B
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28206-2548
Mailing Address - Country:US
Mailing Address - Phone:336-370-9232
Mailing Address - Fax:336-274-7200
Practice Address - Street 1:2103 N GRAHAM ST STE B
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28206-2548
Practice Address - Country:US
Practice Address - Phone:336-370-9232
Practice Address - Fax:336-274-7200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-10
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity HealthGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Multi-Specialty
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty