Provider Demographics
NPI:1750420618
Name:GRAHAM, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:GRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4820 FAYETTEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-2112
Mailing Address - Country:US
Mailing Address - Phone:910-608-0430
Mailing Address - Fax:910-608-0464
Practice Address - Street 1:4820 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-2112
Practice Address - Country:US
Practice Address - Phone:910-608-0430
Practice Address - Fax:910-608-0464
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC16043747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3408879Medicaid