Provider Demographics
NPI:1770768665
Name:FAMILY HEALTHCARE OF LAKE NORMAN PC
Entity type:Organization
Organization Name:FAMILY HEALTHCARE OF LAKE NORMAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:WINEGARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-987-7970
Mailing Address - Street 1:9718 SAM FURR RD
Mailing Address - Street 2:STE. A
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-4978
Mailing Address - Country:US
Mailing Address - Phone:704-987-7970
Mailing Address - Fax:704-987-8221
Practice Address - Street 1:9718 SAM FURR RD
Practice Address - Street 2:STE. A
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4978
Practice Address - Country:US
Practice Address - Phone:704-987-7970
Practice Address - Fax:704-987-8221
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9801807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891178MMedicaid
NC891178MMedicaid
NCG24051Medicare UPIN