Provider Demographics
NPI:1538444815
Name:INNOVATIVE FAMILY CARE OF THE CAROLINA'S
Entity type:Organization
Organization Name:INNOVATIVE FAMILY CARE OF THE CAROLINA'S
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:SHAWNTEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:PICHARDO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:919-264-3398
Mailing Address - Street 1:2515 NC HWY 55
Mailing Address - Street 2:SUITE B
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-1374
Mailing Address - Country:US
Mailing Address - Phone:919-596-0094
Mailing Address - Fax:
Practice Address - Street 1:2515 NC HWY 55
Practice Address - Street 2:SUITE B
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-1374
Practice Address - Country:US
Practice Address - Phone:919-596-0094
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-18
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization