Provider Demographics
NPI:1982652681
Name:CONWAY CHIROPRACTIC CENTER PC
Entity type:Organization
Organization Name:CONWAY CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GAYLORD
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:843-248-5814
Mailing Address - Street 1:1238 PINE ST
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-3402
Mailing Address - Country:US
Mailing Address - Phone:843-248-5814
Mailing Address - Fax:843-248-0116
Practice Address - Street 1:1238 PINE ST
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-3402
Practice Address - Country:US
Practice Address - Phone:843-248-5814
Practice Address - Fax:843-248-0116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1407111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCU6466630281Medicare ID - Type Unspecified