Basic Information
| Provider Information | |||||||||
| NPI: | 1932353208 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHILDREN'S HEALTH OF CAROLINA DBA CUMBERLAND CHILDREN'S CLINIC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CUMBERLAND CHILDREN'S CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1738 OWEN DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103077330 | ||||||||
| FaxNumber: | 9103077334 | ||||||||
| Practice Location | |||||||||
| Address1: | 1738 OWEN DR STE 107 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103077330 | ||||||||
| FaxNumber: | 9103077334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2008 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIAL | ||||||||
| AuthorizedOfficialFirstName: | MELANIE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9107388060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CHILDREN'S HEALTH OF CAROLINA | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.