Provider Demographics
NPI:1265538342
Name:CAROLINA VASCULAR LABORATORY
Entity type:Organization
Organization Name:CAROLINA VASCULAR LABORATORY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:GLENN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:828-696-3833
Mailing Address - Street 1:420 5TH AVE W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28739-4202
Mailing Address - Country:US
Mailing Address - Phone:828-696-3833
Mailing Address - Fax:828-693-6629
Practice Address - Street 1:420 5TH AVE W
Practice Address - Street 2:SUITE 100
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739-4202
Practice Address - Country:US
Practice Address - Phone:828-696-3833
Practice Address - Fax:828-693-6629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0194ROtherBLUE CROSS BLUE SHIELD NC
NC8935971Medicaid
2194978AMedicare UPIN
NC8935971Medicaid