Provider Demographics
NPI:1588714109
Name:INDUSTRICARE
Entity type:Organization
Organization Name:INDUSTRICARE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP RISK MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:CASKEY
Authorized Official - Suffix:
Authorized Official - Credentials:COHC
Authorized Official - Phone:704-597-7228
Mailing Address - Street 1:10616 METROMONT PKWY STE 102
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28269
Mailing Address - Country:US
Mailing Address - Phone:704-597-7228
Mailing Address - Fax:704-597-9190
Practice Address - Street 1:10430 B HARRIS OAKS BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269
Practice Address - Country:US
Practice Address - Phone:704-597-7228
Practice Address - Fax:704-597-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X, 225100000X, 363A00000X
NC34951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC013YMOtherBCBS OF NC