Provider Demographics
NPI:1407926165
Name:METROLINA WOMEN'S BREAST CENTER PLLC
Entity Type:Organization
Organization Name:METROLINA WOMEN'S BREAST CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURENE
Authorized Official - Middle Name:C
Authorized Official - Last Name:MANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-365-8801
Mailing Address - Street 1:439 N WENDOVER ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211
Mailing Address - Country:US
Mailing Address - Phone:704-365-8801
Mailing Address - Fax:704-365-9833
Practice Address - Street 1:439 N WENDOVER ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211
Practice Address - Country:US
Practice Address - Phone:704-365-8801
Practice Address - Fax:704-365-9833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC795388Medicaid
C82348Medicare UPIN
NC204162AMedicare ID - Type Unspecified