Basic Information
| Provider Information | |||||||||
| NPI: | 1205096948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HORTON | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | K. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602484 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045124808 | ||||||||
| FaxNumber: | 7045124838 | ||||||||
| Practice Location | |||||||||
| Address1: | 1333 S DICKINSON DR | ||||||||
| Address2: | SUITE 240 | ||||||||
| City: | LELAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284516430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7045124808 | ||||||||
| FaxNumber: | 7045124838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2008 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 0101249572 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2013-02239 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | Q02239 | 05 | SC | MEDICAID | 1205096948 | 05 | NC | MEDICAID |