Provider Demographics
NPI:1982702684
Name:COLLINS CLINIC OF CHIROPRACTIC & SPORTS MEDICINE, P.A.
Entity type:Organization
Organization Name:COLLINS CLINIC OF CHIROPRACTIC & SPORTS MEDICINE, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GALEN
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:COLLINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-843-5045
Mailing Address - Street 1:PO BOX 1215
Mailing Address - Street 2:526 NORTH BROOME STREET
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-1011
Mailing Address - Country:US
Mailing Address - Phone:704-843-5045
Mailing Address - Fax:704-843-5046
Practice Address - Street 1:526 NORTH BROOME STREET
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-1011
Practice Address - Country:US
Practice Address - Phone:704-843-5045
Practice Address - Fax:704-843-5046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3181111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU98828Medicare UPIN
2457033Medicare ID - Type UnspecifiedMEDICARE