Provider Demographics
NPI:1356876890
Name:MECKLENBURG COUNTY
Entity type:Organization
Organization Name:MECKLENBURG COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN EXTENDER
Authorized Official - Prefix:
Authorized Official - First Name:LISVEL
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:WHNP
Authorized Official - Phone:980-314-9073
Mailing Address - Street 1:7023 PASSERES CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-8002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:249 BILLINGSLEY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1003
Practice Address - Country:US
Practice Address - Phone:980-314-9073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local