Basic Information
| Provider Information | |||||||||
| NPI: | 1932723616 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FOUNDATION HEALTH SYSTEMS, CORP. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
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| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 190 KIMEL PARK DR STE 139 | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271036946 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367186931 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/29/2020 | ||||||||
| LastUpdateDate: | 05/29/2020 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | SHALA | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7043167845 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FOUNDATION HEALTH SYSTEMS, CORP. | ||||||||
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| NPICertificationDate: | 05/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081N0008X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Neuromuscular Medicine |
No ID Information.