Provider Demographics
NPI:1962781047
Name:CARPENTER, JIMMY WAYNE (CPED)
Entity type:Individual
Prefix:MR
First Name:JIMMY
Middle Name:WAYNE
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:CPED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 EDINBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27406-8322
Mailing Address - Country:US
Mailing Address - Phone:336-674-6422
Mailing Address - Fax:336-674-2282
Practice Address - Street 1:4500 INDIANA AVE STE 45
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3269
Practice Address - Country:US
Practice Address - Phone:336-245-4736
Practice Address - Fax:888-812-7934
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist