Provider Demographics
NPI:1609057629
Name:CAROMONT- SOUTH POINT LLC
Entity Type:Organization
Organization Name:CAROMONT- SOUTH POINT LLC
Other - Org Name:SOUTH POINT FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT, CEO
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-834-2133
Mailing Address - Street 1:1220 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:NC
Mailing Address - Zip Code:28012-3370
Mailing Address - Country:US
Mailing Address - Phone:704-825-5333
Mailing Address - Fax:704-825-1751
Practice Address - Street 1:1220 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3370
Practice Address - Country:US
Practice Address - Phone:704-825-5333
Practice Address - Fax:704-825-1751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-19
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5905651Medicaid
NC5905651Medicaid