Provider Demographics
NPI:1710385364
Name:LAKE NORMAN PAIN RELIEF AND WELLNESS
Entity Type:Organization
Organization Name:LAKE NORMAN PAIN RELIEF AND WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:CIPRIANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:980-819-8020
Mailing Address - Street 1:19315 W CATAWBA AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-8650
Mailing Address - Country:US
Mailing Address - Phone:980-819-8020
Mailing Address - Fax:
Practice Address - Street 1:19315 W CATAWBA AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-8650
Practice Address - Country:US
Practice Address - Phone:980-819-8020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-15
Last Update Date:2014-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14902261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
1295807980Medicare PIN