Provider Demographics
NPI:1376976878
Name:NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC
Entity Type:Organization
Organization Name:NC PREVENTATIVE MEDICINE AND WELLNESS CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHRYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-752-7779
Mailing Address - Street 1:7940 WILLIAMS POND LN
Mailing Address - Street 2:SUITE 150
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-8766
Mailing Address - Country:US
Mailing Address - Phone:704-752-7779
Mailing Address - Fax:704-752-7775
Practice Address - Street 1:7940 WILLIAMS POND LN
Practice Address - Street 2:SUITE 150
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-8766
Practice Address - Country:US
Practice Address - Phone:704-752-7779
Practice Address - Fax:704-752-7775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QB0002XAllopathic & Osteopathic PhysiciansFamily MedicineObesity MedicineGroup - Single Specialty