Provider Demographics
NPI:1427483601
Name:CAROLINA EXPRESS CLINIC
Entity type:Organization
Organization Name:CAROLINA EXPRESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:S
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:704-572-0154
Mailing Address - Street 1:5110 PARK RD 1J
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209
Mailing Address - Country:US
Mailing Address - Phone:704-572-0154
Mailing Address - Fax:
Practice Address - Street 1:5110 PARK RD
Practice Address - Street 2:1J
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209
Practice Address - Country:US
Practice Address - Phone:704-496-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-06
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001000254261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1659346492OtherNPI TYPE I: 1659346492