Provider Demographics
NPI:1356642342
Name:CAROLINA HEALTHCARE ASSOCIATES INC
Entity Type:Organization
Organization Name:CAROLINA HEALTHCARE ASSOCIATES INC
Other - Org Name:WALLACE URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODWIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-667-7597
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:704-631-0002
Mailing Address - Fax:
Practice Address - Street 1:112 MEDICAL VILLAGE DR
Practice Address - Street 2:STE G
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-1668
Practice Address - Country:US
Practice Address - Phone:910-285-0333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAROLINA HEALTHCARE ASSOCIATES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-08
Last Update Date:2020-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1356642342Medicaid
NC5916653Medicaid
NC2323961RMedicare PIN