Provider Demographics
NPI:1043310055
Name:CONWAY, JERRY L (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:L
Last Name:CONWAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3689 WATERMELON RD
Mailing Address - Street 2:CAPSTONE CHIROPRACTIC CENTER
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35473-5139
Mailing Address - Country:US
Mailing Address - Phone:205-758-1600
Mailing Address - Fax:205-758-6698
Practice Address - Street 1:3689 WATERMELON RD
Practice Address - Street 2:CAPSTONE CHIROPRACTIC CENTER
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5139
Practice Address - Country:US
Practice Address - Phone:205-758-1600
Practice Address - Fax:205-758-6698
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL728111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51074208OtherBLUE CROSS
ALT68379Medicare UPIN