1366849960 NPI number — TRIAD PRO HEALTH CHIROPRACTIC

Table of content: (NPI 1366849960)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366849960 NPI number — TRIAD PRO HEALTH CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIAD PRO HEALTH 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:
STEVENS CHIROPRACTIC & WELLNESS CENTER
Provider Other Organization Name Type Code:
4
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:
1366849960
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1802 MARTIN LUTHER KING PKWY
Provider Second Line Business Mailing Address:
SUITE 107
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27707-3586
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-401-5061
Provider Business Mailing Address Fax Number:
919-401-8253

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1802 MARTIN LUTHER KING PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
DURHAM
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27707-3586
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-401-5061
Provider Business Practice Location Address Fax Number:
919-401-8253
Provider Enumeration Date:
11/25/2014

Additional Information

Authorized Official

Authorized Official Last Name:
MESILIEN
Authorized Official First Name:
FRITZ
Authorized Official Middle Name:
G.
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
919-401-5061

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4491 , 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: 1073914511 . This is a "NATIONAL PROVIDER NUMBER" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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