Provider Demographics
NPI:1699943548
Name:OM SPA CHIROPRACTIC & WELLNESS,P.C.
Entity type:Organization
Organization Name:OM SPA CHIROPRACTIC & WELLNESS,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:EDMISTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-342-1100
Mailing Address - Street 1:523 FENTON PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1919
Mailing Address - Country:US
Mailing Address - Phone:704-302-1524
Mailing Address - Fax:980-875-9531
Practice Address - Street 1:523 FENTON PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1919
Practice Address - Country:US
Practice Address - Phone:704-302-1524
Practice Address - Fax:980-875-9531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085M2Medicaid
NC89085M2Medicaid