Provider Demographics
NPI:1689757809
Name:CARDINAL CLINIC LLC
Entity Type:Organization
Organization Name:CARDINAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QM MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:DOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:RHIA
Authorized Official - Phone:910-222-6234
Mailing Address - Street 1:1540 PURDUE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-5510
Mailing Address - Country:US
Mailing Address - Phone:910-867-8889
Mailing Address - Fax:910-487-3061
Practice Address - Street 1:841 CIRCLEWOOD DR
Practice Address - Street 2:
Practice Address - City:HAMLET
Practice Address - State:NC
Practice Address - Zip Code:28345-4529
Practice Address - Country:US
Practice Address - Phone:910-582-4171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CARDINAL CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-23
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6603922Medicaid