Provider Demographics
NPI:1770860686
Name:MOORESVILLE PPM LLC
Entity Type:Organization
Organization Name:MOORESVILLE PPM LLC
Other - Org Name:LAKE NORMAN ORTHOPEDIC & SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SR DIR PROV ENROLLMENT & ONBOARDING
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:L
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-3334
Mailing Address - Street 1:4000 MERIDIAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6325
Mailing Address - Country:US
Mailing Address - Phone:615-465-7230
Mailing Address - Fax:
Practice Address - Street 1:202 WILLIAMSON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-7610
Practice Address - Country:US
Practice Address - Phone:704-799-7811
Practice Address - Fax:704-799-7812
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MOORESVILLE PPM LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-11-05
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2347341Medicare PIN