Provider Demographics
NPI:1073892873
Name:IMAGINE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:IMAGINE CHIROPRACTIC PC
Other - Org Name:PAIN RELIEF CENTER OF MOUNT PLEASANT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:VICORY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-416-8882
Mailing Address - Street 1:952 HOUSTON NORTHCUTT BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5659
Mailing Address - Country:US
Mailing Address - Phone:843-416-8882
Mailing Address - Fax:843-416-8929
Practice Address - Street 1:952 HOUSTON NORTHCUTT BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5659
Practice Address - Country:US
Practice Address - Phone:843-416-8882
Practice Address - Fax:843-416-8929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-10
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20010688261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center