Provider Demographics
NPI:1811253065
Name:ROCKY MOUNT PAIN AND SPINE
Entity type:Organization
Organization Name:ROCKY MOUNT PAIN AND SPINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:252-200-5180
Mailing Address - Street 1:121 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-9516
Mailing Address - Country:US
Mailing Address - Phone:252-200-5180
Mailing Address - Fax:252-200-5186
Practice Address - Street 1:7780 BRIER CREEK PKWY
Practice Address - Street 2:200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27617-7849
Practice Address - Country:US
Practice Address - Phone:919-596-3400
Practice Address - Fax:919-596-3499
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-02
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141911261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC141911OtherSTATE LICENSE
NC5915893Medicaid
NC5915893Medicaid