Basic Information
| Provider Information | |||||||||
| NPI: | 1467650440 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROLINA MEDICAL SPECIALTIES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 53277 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283053277 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104850500 | ||||||||
| FaxNumber: | 9104852600 | ||||||||
| Practice Location | |||||||||
| Address1: | 420 RALEIGH ST | ||||||||
| Address2: | SUITE D | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284126316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104520999 | ||||||||
| FaxNumber: | 9104522935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2007 | ||||||||
| LastUpdateDate: | 07/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | SLEEM | ||||||||
| AuthorizedOfficialFirstName: | DIMITRI | ||||||||
| AuthorizedOfficialMiddleName: | K. | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9109775511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAROLINA MEDICAL SPECIALTIES, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BC3200X | 01163 | NC | N | Suppliers | Durable Medical Equipment & Medical Supplies | Customized Equipment | 335E00000X | 01163 | NC | N | Suppliers | Prosthetic/Orthotic Supplier | 332B00000X | 01163 | NC | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 01163 | 01 | NC | BOARD OF PHARMACY PERMIT | OTHER |