1134160054 NPI number — DAIL CHIROPRACTIC CLINIC PA

Table of content: (NPI 1134160054)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134160054 NPI number — DAIL CHIROPRACTIC CLINIC PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAIL CHIROPRACTIC CLINIC PA
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:
1134160054
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1655 BROAD RIVER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLUMBIA
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29210-7303
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
803-772-8680
Provider Business Mailing Address Fax Number:
803-772-5241

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1655 BROAD RIVER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLUMBIA
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29210-7395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
803-772-8680
Provider Business Practice Location Address Fax Number:
803-772-5241
Provider Enumeration Date:
06/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DAIL
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
EUGENE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
803-772-8680

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  C0583 , 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: $$$$$$$$$ . This is a "SSN" identifier . This identifiers is of the category "OTHER".




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