NCC211423_Contact Update Record (Legally Resp Change)_20230321

Action History (UTC-05:00) Eastern Time (US & Canada)
Submit by bethany.georgoulias 3/21/2023 10:26:51 AM (Contact Changes Submitted)

Certificate of NCC211423
Coverage (COC) No.* Enter the Certificate of Coverage Number (Use capital letters)
NC Reference No. NCG01-2021-1423
Original NOI No.* 47501
Project information associated with this permit (cannot change):
Permittee Listed Organizaiton cannot be changed (new COC required)
The Charlotte Mecklenburg Hospital Authority
Project Name Atrium Union West Offsite Roadway (Express Review)
Address 1500 Stallings Road, Stallings, NC
County Union
Latitude 35.0957
Longitude-80.6780
Date COC Issued* 03/10/2021
Prior Rescission Date This field will populate only if COC has already been rescinded.
Which Contacts Have Billing Only
Changed?* Legally Responsible Individual Only
Site Contact Only
BOTH Legally Responsible Individual and Site Contact
Has Billing Contact Choose'Yes'to revise Billing Contact details.
Changed? No
Yes
Billing Email [e-mail]
NEW Billing Email [e-mail]
Billing Telephone No. 704-667-9428
NEW Billing [phone]
Telephone No. (Optional)
Legally Responsible Individual Contact Information
REVISE ONLY WHERE NECESSARY. KEEP INFORMATION THESAME IF NO CHANGES!
Legally Responsible Tom Washington
Individual (Previous)
First Name (New)* Amanda
Last Name (New)* Mewborn

NEW Legally Reflects any revisions above
Responsible Amanda Mewborn
Individual*
Permittee Email
[e-mail]
(Previous)
NEW Permittee
[e-mail]
Email*
Permittee Telephone
704-667-9428
No. (Previous)
NEW Permittee
[phone]
Telephone No.*
Permittee Mailing Post Office Box 32861, 0, Charlotte, North
Address (Previous) Carolina 28203-5812
NEW Permittee Street Address
Mailing Address* Post Office Box 32861
Address Line 2
City
State / Province / Region
Charlotte
North Carolina
Postal / Zip Code
Country
28232-2861
USA
Permittee Street 1000 Blythe Boulevard, 0, Charlotte, NC
Address (Previous) 28203-5812
NEW Permittee Street Street Address
Address* 1000 Blythe Boulevard
Address Line 2
City
State / Province / Region
Charlotte
NC
Postal / Zip Code
Country
28203-5812
US
Change Requested Nathan Tidd (Kimley-Horn) via email request and verified by Amanda Mewborn
by: * (Vice President, Atrium Health) on 3/20/2023.
Include any additional correspondence records in the Repository COC folder.
Additional Information for this update to contact information:
Addional Explanation
(Optional)
Date * 03/21 /2023