Provider Demographics
NPI:1720123862
Name:CAROLINA MEDICAL SUPPLY LLC
Entity Type:Organization
Organization Name:CAROLINA MEDICAL SUPPLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:WARE
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:704-730-9500
Mailing Address - Street 1:1802 SHELBY RD
Mailing Address - Street 2:
Mailing Address - City:KINGS MTN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-8900
Mailing Address - Country:US
Mailing Address - Phone:704-730-9500
Mailing Address - Fax:704-730-9501
Practice Address - Street 1:1802 SHELBY RD
Practice Address - Street 2:
Practice Address - City:KINGS MTN
Practice Address - State:NC
Practice Address - Zip Code:28086-8900
Practice Address - Country:US
Practice Address - Phone:704-730-9500
Practice Address - Fax:704-730-9501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703174Medicaid
NC5450360001Medicare NSC