Provider Demographics
NPI:1285034132
Name:PARKS, CARLA J
Entity type:Individual
Prefix:
First Name:CARLA
Middle Name:J
Last Name:PARKS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 VERDAE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-3827
Mailing Address - Country:US
Mailing Address - Phone:864-386-6209
Mailing Address - Fax:
Practice Address - Street 1:101 VERDAE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-3832
Practice Address - Country:US
Practice Address - Phone:864-288-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-28
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCHAS-0465172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker