Provider Demographics
NPI:1730903436
Name:NEOGENIX LAKE NORMAN, PC
Entity type:Organization
Organization Name:NEOGENIX LAKE NORMAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:NIKITAS
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:MILES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-727-6551
Mailing Address - Street 1:16147 LANCASTER HWY STE 140
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-4782
Mailing Address - Country:US
Mailing Address - Phone:704-727-6551
Mailing Address - Fax:
Practice Address - Street 1:19475 OLD JETTON RD STE 102
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:NC
Practice Address - Zip Code:28031-6591
Practice Address - Country:US
Practice Address - Phone:704-727-6551
Practice Address - Fax:704-669-8670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty