Provider Demographics
NPI:1104154988
Name:CAROLINA MERCY MEDICAL CLINIC PC
Entity type:Organization
Organization Name:CAROLINA MERCY MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CORNELIUS
Authorized Official - Middle Name:S
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:704-867-8855
Mailing Address - Street 1:2101 W FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-1338
Mailing Address - Country:US
Mailing Address - Phone:704-867-8855
Mailing Address - Fax:704-867-1414
Practice Address - Street 1:2101 W FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-1338
Practice Address - Country:US
Practice Address - Phone:704-867-8855
Practice Address - Fax:704-867-1414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-07
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200100074261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care