Basic Information
| Provider Information | |||||||||
| NPI: | 1063802718 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA OUTREACH, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 HAY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104380939 | ||||||||
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| Address1: | 911 HAY ST | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283055313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104380939 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2015 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | ROB | ||||||||
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| AuthorizedOfficialTitleorPosition: | HUMAN RESOURCES | ||||||||
| AuthorizedOfficialTelephone: | 9192519001 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 34D2070270 | NC | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 34D2085455 | 01 | NC | CLIA CERTIFICATION | OTHER |