1831597772 NPI number — CLOUSE CHIROPRACTIC SERVICES LLC

Table of content: (NPI 1831597772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831597772 NPI number — CLOUSE CHIROPRACTIC SERVICES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLOUSE CHIROPRACTIC SERVICES 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:
MONCKS CORNER CHIROPRACTIC
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:
1831597772
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
505 N HIGHWAY 52
Provider Second Line Business Mailing Address:
SUITE D #127
Provider Business Mailing Address City Name:
MONCKS CORNER
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29461-3151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-761-4470
Provider Business Mailing Address Fax Number:
843-695-7932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 BROUGHTON RD
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
MONCKS CORNER
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29461-4021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-761-4470
Provider Business Practice Location Address Fax Number:
843-695-7932
Provider Enumeration Date:
12/09/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MCCOY
Authorized Official First Name:
NICHOLAS
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MEMBER/PROVIDOR
Authorized Official Telephone Number:
843-761-4470

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3453 , 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: DW2715 . This is a "RAILROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




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