Provider Demographics
NPI:1912969106
Name:CAROLINA FAMILY MEDICINE & WELLNESS
Entity Type:Organization
Organization Name:CAROLINA FAMILY MEDICINE & WELLNESS
Other - Org Name:CFMW, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ALISSANDRO
Authorized Official - Middle Name:R
Authorized Official - Last Name:CASTILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-662-3627
Mailing Address - Street 1:478 WILLIAMSON RD.
Mailing Address - Street 2:SUITE B
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27117-9109
Mailing Address - Country:US
Mailing Address - Phone:704-662-3627
Mailing Address - Fax:704-662-3229
Practice Address - Street 1:478 WILLIAMSON RD.
Practice Address - Street 2:SUITE B
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:27117-9109
Practice Address - Country:US
Practice Address - Phone:704-662-3627
Practice Address - Fax:704-662-3229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900793305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015VYMedicaid
NC015VYOtherBLUE CROSS/BLUE SHIELD
NC015VYOtherBLUE CROSS/BLUE SHIELD