Provider Demographics
NPI:1780684522
Name:HEAD INJURY CENTER OF CHARLOTTE, INC.
Entity Type:Organization
Organization Name:HEAD INJURY CENTER OF CHARLOTTE, INC.
Other - Org Name:CAROLINA NEUROSERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:EWERT
Authorized Official - Suffix:
Authorized Official - Credentials:PH D
Authorized Official - Phone:704-366-9930
Mailing Address - Street 1:6853 FAIRVIEW RD
Mailing Address - Street 2:STE B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3363
Mailing Address - Country:US
Mailing Address - Phone:704-366-9930
Mailing Address - Fax:704-366-9931
Practice Address - Street 1:6853 FAIRVIEW RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3363
Practice Address - Country:US
Practice Address - Phone:704-366-9930
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-22
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2340104AMedicare PIN
NC2340104Medicare PIN