Provider Demographics
NPI:1285056630
Name:CAROLINA SPORTS, SPINE & WELLNESS CENTER, PLLC
Entity type:Organization
Organization Name:CAROLINA SPORTS, SPINE & WELLNESS CENTER, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:419-494-7169
Mailing Address - Street 1:PO BOX 13647
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27415-3647
Mailing Address - Country:US
Mailing Address - Phone:336-763-3756
Mailing Address - Fax:336-763-3757
Practice Address - Street 1:3150 N ELM ST
Practice Address - Street 2:SUITE 103
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-3880
Practice Address - Country:US
Practice Address - Phone:336-763-3756
Practice Address - Fax:336-763-3757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-19
Last Update Date:2014-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCG236C2532528Medicaid
NC12377167OtherCAQH
NCNC6179AOtherMEDICARE PTAN