Basic Information
| Provider Information | |||||||||
| NPI: | 1356587893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CATAWBA VALLEY MEDICAL CENTER | ||||||||
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| OtherOrganizationName: | THE HEALTHY HOUSE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 890273 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282890273 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
| FaxNumber: | 8283263371 | ||||||||
| Practice Location | |||||||||
| Address1: | 810 FAIRGROVE CHURCH RD | ||||||||
| Address2: | |||||||||
| City: | HICKORY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286029617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8283263809 | ||||||||
| FaxNumber: | 8283263371 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2009 | ||||||||
| LastUpdateDate: | 09/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | BOONE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SR. VICE PRESIDENT/FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8283263809 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | H0223 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5912041 | 05 | NC | MEDICAID | 201A4 | 01 | NC | NC BLUE CROSS BLUE SHIELD | OTHER |