Provider Demographics
NPI:1063465045
Name:MYCHIROCLUB, P.A.
Entity Type:Organization
Organization Name:MYCHIROCLUB, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:NEAL
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:LANGE
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:843-236-6291
Mailing Address - Street 1:4012 POSTAL WAY
Mailing Address - Street 2:SUITE A
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-3537
Mailing Address - Country:US
Mailing Address - Phone:843-236-6291
Mailing Address - Fax:843-872-9190
Practice Address - Street 1:4012 POSTAL WAY STE A
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-3298
Practice Address - Country:US
Practice Address - Phone:843-236-6291
Practice Address - Fax:843-872-9190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2874111N00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12137533OtherMULTIPLAN
SC2164911OtherFIRST HEALTH
SC2164911OtherCCN
SCGCH435Medicaid
SC12137533OtherMULTIPLAN
SC=========OtherPRIVATE HEALTHCARE SYSTEM
SC=========OtherBCBS
SC=========OtherSTATE HEALTH PLAN
SC=========OtherUNITED HEALTHCARE
SC=========OtherBLUECHOICE HEALTHPLAN
SC2164911OtherCCN
SC=========OtherACN GROUP
SCGCH435Medicaid
SC=========OtherBCBS
SC=========OtherAETNA