Provider Demographics
NPI:1659815140
Name:CAROLINA CENTER FOR RESTORATIVE MEDICINE
Entity Type:Organization
Organization Name:CAROLINA CENTER FOR RESTORATIVE MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:STEPHENIA
Authorized Official - Middle Name:BENITA
Authorized Official - Last Name:JEFFRIES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-803-4268
Mailing Address - Street 1:809 SPRING FOREST RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-9700
Mailing Address - Country:US
Mailing Address - Phone:919-803-4268
Mailing Address - Fax:919-977-1381
Practice Address - Street 1:809 SPRING FOREST RD
Practice Address - Street 2:SUITE 100
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-9198
Practice Address - Country:US
Practice Address - Phone:919-803-4268
Practice Address - Fax:919-977-1381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC363302083P0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8923469Medicaid
NC23469OtherBCBS