Provider Demographics
NPI:1528169638
Name:KILDAIRE CHIROPRACTIC, SPORTS MEDICINE AND WELLNESS CENTER, P.A.
Entity type:Organization
Organization Name:KILDAIRE CHIROPRACTIC, SPORTS MEDICINE AND WELLNESS CENTER, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF BUSINESS
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:ALLEN
Authorized Official - Last Name:SWANK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:919-460-6098
Mailing Address - Street 1:105 KILMAYNE DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27511-4433
Mailing Address - Country:US
Mailing Address - Phone:919-469-8897
Mailing Address - Fax:919-469-5606
Practice Address - Street 1:105 KILMAYNE DR
Practice Address - Street 2:SUITE B
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27511-4433
Practice Address - Country:US
Practice Address - Phone:919-469-8897
Practice Address - Fax:919-469-5606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3508111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty