1285730697 NPI number — MT. OLIVE CHIROPRACTIC CLINIC, P.C.

Table of content: (NPI 1285730697)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285730697 NPI number — MT. OLIVE CHIROPRACTIC CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MT. OLIVE CHIROPRACTIC CLINIC, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1285730697
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
515 W MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT OLIVE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28365-1903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-658-0003
Provider Business Mailing Address Fax Number:
919-658-0310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
515 W MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNT OLIVE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28365-1903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-658-0003
Provider Business Practice Location Address Fax Number:
919-658-0310
Provider Enumeration Date:
09/15/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MOTAMED
Authorized Official First Name:
MASSOUD
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT, D.C.
Authorized Official Telephone Number:
919-658-0003

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2404 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0820M . This is a "BLUE CROSS" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0820M . This is a "BLUE SHIELD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 890820M , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".