Provider Demographics
NPI:1063570919
Name:NODRICK, DALE LJ (DC)
Entity type:Individual
Prefix:DR
First Name:DALE
Middle Name:LJ
Last Name:NODRICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:DILLON
Mailing Address - State:SC
Mailing Address - Zip Code:29536-3318
Mailing Address - Country:US
Mailing Address - Phone:843-487-5123
Mailing Address - Fax:843-487-5121
Practice Address - Street 1:200 S 3RD AVE
Practice Address - Street 2:
Practice Address - City:DILLON
Practice Address - State:SC
Practice Address - Zip Code:29536-3318
Practice Address - Country:US
Practice Address - Phone:843-487-5123
Practice Address - Fax:843-487-5121
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2017-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2235111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH259Medicaid
SCCH2235Medicaid
SCCH2235Medicaid
SC6779Medicare PIN