Provider Demographics
NPI:1144275124
Name:DPMMOFFETTNRNC LLC
Entity type:Organization
Organization Name:DPMMOFFETTNRNC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:COLIN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOFFETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:704-438-1821
Mailing Address - Street 1:2017 SPRUCEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-8117
Mailing Address - Country:US
Mailing Address - Phone:704-438-1821
Mailing Address - Fax:
Practice Address - Street 1:1000 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28697-2732
Practice Address - Country:US
Practice Address - Phone:704-438-1821
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC139213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908125Medicaid
NC8908125Medicaid
NC243063Medicare ID - Type Unspecified