Provider Demographics
NPI:1962588798
Name:NORTH MYRTLE BEACH CHIROPRACTIC PC
Entity type:Organization
Organization Name:NORTH MYRTLE BEACH CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-280-7000
Mailing Address - Street 1:513 HIGHWAY 17 N
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-2903
Mailing Address - Country:US
Mailing Address - Phone:843-280-7000
Mailing Address - Fax:843-280-7001
Practice Address - Street 1:513 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-2903
Practice Address - Country:US
Practice Address - Phone:843-280-7000
Practice Address - Fax:843-280-7001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-27
Last Update Date:2011-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1652111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085MRMedicaid
SCCH1652Medicaid
SC5924Medicare PIN