1356556815 NPI number — GRAVELY CHIROPRACTIC PC

Table of content: (NPI 1356556815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356556815 NPI number — GRAVELY CHIROPRACTIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GRAVELY CHIROPRACTIC PC
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:
GRAVELY CHIROPRACTIC AND WELLNESS
Provider Other Organization Name Type Code:
3
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:
1356556815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE BEACH
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36561-2157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-980-2225
Provider Business Mailing Address Fax Number:
251-980-2779

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4223 ORANGE BEACH BLVD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
ORANGE BEACH
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36561-3459
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-980-2225
Provider Business Practice Location Address Fax Number:
251-980-2778
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GRAVELY
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
W
Authorized Official Title or Position:
CHIROPRACTOR
Authorized Official Telephone Number:
251-980-2225

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2132 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 32474 . This is a "BCBS OF AL" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: K750 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com