Basic Information
Provider Information | |||||||||
NPI: | 1659351724 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CLECO PRIMARY CARE NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UPPER CLEVELAND MEDICAL CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 808 SCHENCK STREET | ||||||||
Address2: |   | ||||||||
City: | SHELBY | ||||||||
State: | NC | ||||||||
PostalCode: | 281503934 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044801087 | ||||||||
FaxNumber: | 7044843260 | ||||||||
Practice Location | |||||||||
Address1: | 5009 FALLSTON ROAD | ||||||||
Address2: |   | ||||||||
City: | LAWNDALE | ||||||||
State: | NC | ||||||||
PostalCode: | 28090 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7044809344 | ||||||||
FaxNumber: | 7045385803 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2006 | ||||||||
LastUpdateDate: | 03/21/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JORDAN | ||||||||
AuthorizedOfficialFirstName: | MICHELLE | ||||||||
AuthorizedOfficialMiddleName: | HOYLE | ||||||||
AuthorizedOfficialTitleorPosition: | FINANCIAL MANAGER | ||||||||
AuthorizedOfficialTelephone: | 7044801087 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | CLECO PRIMARY CARE NETWORK | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
ID | Type | State | Issuer | Description | 343955A | 05 | NC |   | MEDICAID |