Provider Demographics
NPI:1386714681
Name:SOUTHPARK CHIROPRACTIC CENTER INC
Entity type:Organization
Organization Name:SOUTHPARK CHIROPRACTIC CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:HILL
Authorized Official - Last Name:AVERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-362-5400
Mailing Address - Street 1:6626 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210
Mailing Address - Country:US
Mailing Address - Phone:704-362-5400
Mailing Address - Fax:
Practice Address - Street 1:6626 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:704-362-5400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1812111N00000X
SC2553111N00000X
FLCH5078111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0853BOtherBLUE CROSS BLUE SHIELD
NC2447317Medicare ID - Type Unspecified
NC0853BOtherBLUE CROSS BLUE SHIELD