Provider Demographics
NPI:1881624955
Name:CAROLINA PODIATRY ASSOCIATES, LLC
Entity type:Organization
Organization Name:CAROLINA PODIATRY ASSOCIATES, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:B
Authorized Official - Last Name:NETTLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-904-0648
Mailing Address - Street 1:P O BOX 777
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-2527
Mailing Address - Country:US
Mailing Address - Phone:910-904-0648
Mailing Address - Fax:910-904-1810
Practice Address - Street 1:402 S MAIN ST
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376-3223
Practice Address - Country:US
Practice Address - Phone:910-904-0648
Practice Address - Fax:910-904-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24580174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC016TMOtherBLUECROSSBLUESHIELD NUMBE
NC89016TMMedicaid
NC5352990001Medicare NSC
NC89016TMMedicaid