Provider Demographics
NPI:1902150832
Name:INFINITE WELLNESS OF THE CAROLINAS
Entity Type:Organization
Organization Name:INFINITE WELLNESS OF THE CAROLINAS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:K
Authorized Official - Last Name:INGRAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-547-4343
Mailing Address - Street 1:2530 W ROOSEVELT BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28110-8468
Mailing Address - Country:US
Mailing Address - Phone:704-774-1703
Mailing Address - Fax:
Practice Address - Street 1:2530 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-8468
Practice Address - Country:US
Practice Address - Phone:704-774-1703
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-30
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6723360001Medicare NSC