Provider Demographics
NPI:1013015205
Name:FAYETTEVILLE CHIROPRACTIC
Entity Type:Organization
Organization Name:FAYETTEVILLE CHIROPRACTIC
Other - Org Name:FAYETTEVILLE FAMILY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:E
Authorized Official - Last Name:FONKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-484-5999
Mailing Address - Street 1:424 GRAYLYN PL
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28314-2630
Mailing Address - Country:US
Mailing Address - Phone:910-864-8180
Mailing Address - Fax:
Practice Address - Street 1:205 OWEN DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3409
Practice Address - Country:US
Practice Address - Phone:910-484-5999
Practice Address - Fax:910-484-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2015-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1875111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0840GOtherBCBS OF NC
NC890823WMedicaid
NCU33454Medicare UPIN
NC2449618Medicare ID - Type Unspecified