Provider Demographics
NPI:1578761367
Name:CANDELARIA, CAROLINA ANNA (MSPT)
Entity Type:Individual
Prefix:MS
First Name:CAROLINA
Middle Name:ANNA
Last Name:CANDELARIA
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 NE 42ND ST
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-5450
Mailing Address - Country:US
Mailing Address - Phone:910-278-6794
Mailing Address - Fax:910-278-6794
Practice Address - Street 1:1102 N HOWE ST BLDG L
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-3042
Practice Address - Country:US
Practice Address - Phone:910-278-6794
Practice Address - Fax:910-278-6794
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2675225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC079CKOtherBCBSNC
NC202200515OtherEIN
NC2504296AMedicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
NC2346034Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER