1104075183 NPI number — REAL CHIROPRACTIC LLC

Table of content: (NPI 1104075183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104075183 NPI number — REAL CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REAL CHIROPRACTIC LLC
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:
DBA CAUSEY FAMILY 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:
1104075183
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/29/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30847
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29588-0015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-903-5772
Provider Business Mailing Address Fax Number:
843-903-5774

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4999 CAROLINA FOREST BLVD
Provider Second Line Business Practice Location Address:
UNIT 12
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29579-3587
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-903-5772
Provider Business Practice Location Address Fax Number:
843-903-5774
Provider Enumeration Date:
09/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
CAUSEY
Authorized Official First Name:
ZACHARY
Authorized Official Middle Name:
G
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
843-903-5772

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2119 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10995635 . This is a "CAQH" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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