1225227796 NPI number — WALRAVEN CHIROPRACTIC

Table of content: (NPI 1225227796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225227796 NPI number — WALRAVEN CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WALRAVEN CHIROPRACTIC
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:
1225227796
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10214 CHESTNUT PLAZA DR
Provider Second Line Business Mailing Address:
SUITE 190
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46814-8970
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-625-6660
Provider Business Mailing Address Fax Number:
260-625-6661

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3010 MONROE RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28205-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-334-3761
Provider Business Practice Location Address Fax Number:
704-334-3763
Provider Enumeration Date:
10/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WALRAVEN
Authorized Official First Name:
DARCEY
Authorized Official Middle Name:
Authorized Official Title or Position:
DR
Authorized Official Telephone Number:
704-334-3761

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3275 , 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: 5908612 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 89085UH , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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