Basic Information
| Provider Information | |||||||||
| NPI: | 1053393272 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CELO HEALTH EDUCATION CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CELO HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 SEVEN MILE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287148509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286754116 | ||||||||
| FaxNumber: | 8286759312 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 SEVEN MILE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | BURNSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287148509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8286754116 | ||||||||
| FaxNumber: | 8286759312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2005 | ||||||||
| LastUpdateDate: | 02/05/2010 | ||||||||
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| AuthorizedOfficialLastName: | BARNETT | ||||||||
| AuthorizedOfficialFirstName: | DEBORA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8286754116 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8901230 | 05 | NC | MEDICAID |