Provider Demographics
NPI:1457391542
Name:CAH ACQUISITION COMPANY 1 LLC
Entity type:Organization
Organization Name:CAH ACQUISITION COMPANY 1 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:TONDA
Authorized Official - Middle Name:DEANN
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:580-303-0840
Mailing Address - Street 1:7920 BELT LINE RD STE 215
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8155
Mailing Address - Country:US
Mailing Address - Phone:214-502-9624
Mailing Address - Fax:252-793-7740
Practice Address - Street 1:958 US HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NC
Practice Address - Zip Code:27962
Practice Address - Country:US
Practice Address - Phone:252-793-4135
Practice Address - Fax:252-793-7740
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CAH ACQUISITION COMPANY 1 LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-07
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 207R00000X, 208M00000X, 363A00000X
NC367500000X
NCH0006207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8907742Medicaid
NC2335749Medicare Oscar/Certification