Provider Demographics
NPI:1285099804
Name:CHARLOTTE RESTORATION
Entity type:Organization
Organization Name:CHARLOTTE RESTORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:
Authorized Official - Last Name:SEMEKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-617-2649
Mailing Address - Street 1:5970 FAIRVIEW RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3167
Mailing Address - Country:US
Mailing Address - Phone:704-617-2649
Mailing Address - Fax:
Practice Address - Street 1:5970 FAIRVIEW RD
Practice Address - Street 2:SUITE 215
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3167
Practice Address - Country:US
Practice Address - Phone:704-617-2649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-25
Last Update Date:2015-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400163261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty