Provider Demographics
NPI:1528127099
Name:KOSTERMAN CHIROPRACTIC CENTER, P.A.
Entity type:Organization
Organization Name:KOSTERMAN CHIROPRACTIC CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:KOSTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-592-2250
Mailing Address - Street 1:401 COOPER DRIVE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2898
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:401 COOPER DRIVE
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2898
Practice Address - Country:US
Practice Address - Phone:910-592-2250
Practice Address - Fax:910-592-6149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:KOSTERMAN CHIROPRACTIC CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-12-08
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001407900111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2446510Medicare PIN