Provider Demographics
NPI:1073528899
Name:INDIAN TRAIL SPECIFIC CHIROPRACTIC INC
Entity Type:Organization
Organization Name:INDIAN TRAIL SPECIFIC CHIROPRACTIC INC
Other - Org Name:CAROLINAS FAMILY SPINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORINNE
Authorized Official - Middle Name:EASTERLING
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-882-1488
Mailing Address - Street 1:14015 INDEPENDENCE BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-9668
Mailing Address - Country:US
Mailing Address - Phone:704-882-1488
Mailing Address - Fax:704-882-1448
Practice Address - Street 1:14015 INDEPENDENCE BLVD STE D
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-9668
Practice Address - Country:US
Practice Address - Phone:704-882-1488
Practice Address - Fax:704-882-1448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3225111NT0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NT0100XChiropractic ProvidersChiropractorThermographyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89015PPMedicaid
NC2457097Medicare ID - Type Unspecified
NC89015PPMedicaid