Organization
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Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. WONONA MICHELLE LEWIS (OWNER)
(704) 668-7319
Entity
Organization
Contact information
Practice address
10004 FARM POND RD, INDIAN TRAIL, NC 28079-5787
(704) 668-7319
Mailing address
10004 FARM POND RD, INDIAN TRAIL, NC 28079-5787
(704) 668-7319
Taxonomy
Speciality
Code
Description
License number
State
302F00000X
Exclusive Provider Organization
Primary
—
—
Other
Enumeration date
10/10/2016
Last updated
10/10/2016
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