Provider Demographics
NPI:1760418917
Name:WAVECO LLC
Entity Type:Organization
Organization Name:WAVECO LLC
Other - Org Name:CAROLINA CENTER FOR SPECIALTY SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER BOARD OF DIRECTORS
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CLONINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-376-1605
Mailing Address - Street 1:1822 BRUNSWICK AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1820
Mailing Address - Country:US
Mailing Address - Phone:704-831-4400
Mailing Address - Fax:704-831-4401
Practice Address - Street 1:1822 BRUNSWICK AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1820
Practice Address - Country:US
Practice Address - Phone:704-831-4400
Practice Address - Fax:704-831-4401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCAS0058261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1760418917Medicaid
NC2380827Medicare PIN