Basic Information
| Provider Information | |||||||||
| NPI: | 1609057629 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAROMONT- SOUTH POINT LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SOUTH POINT FAMILY PRACTICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1220 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | BELMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280123370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048255333 | ||||||||
| FaxNumber: | 7048251751 | ||||||||
| Practice Location | |||||||||
| Address1: | 1220 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | BELMONT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280123370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048255333 | ||||||||
| FaxNumber: | 7048251751 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2007 | ||||||||
| LastUpdateDate: | 06/10/2015 | ||||||||
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| AuthorizedOfficialLastName: | LUCKETT | ||||||||
| AuthorizedOfficialFirstName: | DOUGLAS | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT, CEO | ||||||||
| AuthorizedOfficialTelephone: | 7048342133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5905651 | 05 | NC | MEDICAID |