Provider Demographics
NPI:1376013243
Name:MISSION HEALTH COMMUNITY MULTISPECIALTY PROVIDERS, LLC
Entity Type:Organization
Organization Name:MISSION HEALTH COMMUNITY MULTISPECIALTY PROVIDERS, LLC
Other - Org Name:DENTIST
Other - Org Type:Other Name
Authorized Official - Title/Position:GROUP VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TEDRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-372-3755
Mailing Address - Street 1:PO BOX 603366
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3366
Mailing Address - Country:US
Mailing Address - Phone:828-213-1500
Mailing Address - Fax:828-681-1575
Practice Address - Street 1:11 VANDERBILT PARK DR
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28803-1700
Practice Address - Country:US
Practice Address - Phone:828-213-1740
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MISSION HEALTH COMMUNITY MULTISPECIALTY PROVIDERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-12-04
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC02CG9OtherBC/BS NC
NC1376013243Medicaid