Provider Demographics
NPI:1598101974
Name:CAROLINA PAIN AND WEIGHT LOSS
Entity Type:Organization
Organization Name:CAROLINA PAIN AND WEIGHT LOSS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:704-360-4564
Mailing Address - Street 1:131 WELTON WAY
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9163
Mailing Address - Country:US
Mailing Address - Phone:704-360-4564
Mailing Address - Fax:704-360-4553
Practice Address - Street 1:131 WELTON WAY
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9163
Practice Address - Country:US
Practice Address - Phone:704-360-4564
Practice Address - Fax:704-360-4553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-13
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201516261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP69057Medicare UPIN
NC1942237409Medicare PIN