Provider Demographics
NPI:1912142167
Name:MARIETTA MEDICAL CLINIC, PA
Entity Type:Organization
Organization Name:MARIETTA MEDICAL CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IFEANYI
Authorized Official - Middle Name:O
Authorized Official - Last Name:OKAFOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-866-8030
Mailing Address - Street 1:PO BOX 550457
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28055-0457
Mailing Address - Country:US
Mailing Address - Phone:704-866-8030
Mailing Address - Fax:
Practice Address - Street 1:401 S MARIETTA ST
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-4331
Practice Address - Country:US
Practice Address - Phone:704-866-8030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200150174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty