Provider Demographics
NPI:1518214022
Name:SICKEROTT, CARL DIEDRITCH JR
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:DIEDRITCH
Last Name:SICKEROTT
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2316
Mailing Address - Country:US
Mailing Address - Phone:919-946-1758
Mailing Address - Fax:
Practice Address - Street 1:2026 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27608-2316
Practice Address - Country:US
Practice Address - Phone:919-946-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCMHL-092-469311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7804353Medicaid