Provider Demographics
NPI:1023383163
Name:PETRY CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:PETRY CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:PETRY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:256-891-3733
Mailing Address - Street 1:700 AL HIGHWAY 75 N
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35951-4014
Mailing Address - Country:US
Mailing Address - Phone:256-891-3733
Mailing Address - Fax:256-891-0602
Practice Address - Street 1:700 AL HIGHWAY 75 N
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:AL
Practice Address - Zip Code:35951-4014
Practice Address - Country:US
Practice Address - Phone:256-891-3733
Practice Address - Fax:256-891-0602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-21
Last Update Date:2012-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1566305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51518312OtherBLUE CROSS BLUE SHIELD
AL051553979Medicare PIN
AL51518312OtherBLUE CROSS BLUE SHIELD