Organization
INDIAN TRAIL FAMILY MEDICINE
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DANIEL L WIENS (SENIOR VICE PRESIDENT)
(704) 355-0648
Entity
Organization
Contact information
Practice address
4503 OLD MONROE RD, INDIAN TRAIL, NC 28079-5309
(704) 821-6900
(704) 821-6911
Mailing address
5000 AIRPORT CENTER PKWY STE A, CHARLOTTE, NC 28208-5899
(704) 512-4116
(704) 371-7284
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
7901052
—
NC
Enumeration date
06/24/2006
Last updated
02/12/2008
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