Provider Demographics
NPI:1790191765
Name:MCPC-5, LLC
Entity Type:Organization
Organization Name:MCPC-5, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEJACO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-715-1913
Mailing Address - Street 1:PO BOX 896208
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6208
Mailing Address - Country:US
Mailing Address - Phone:910-417-4105
Mailing Address - Fax:910-417-4120
Practice Address - Street 1:812 CANDY PARK RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:NC
Practice Address - Zip Code:28372-9120
Practice Address - Country:US
Practice Address - Phone:910-417-4105
Practice Address - Fax:910-417-4120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-10
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty