Provider Demographics
NPI:1083611040
Name:DRISCOLL, TINA MARIE (DC)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:DRISCOLL
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 GLENOLA ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28311-3206
Mailing Address - Country:US
Mailing Address - Phone:910-822-3221
Mailing Address - Fax:
Practice Address - Street 1:1171 N BRAGG BLVD
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NC
Practice Address - Zip Code:28390-3116
Practice Address - Country:US
Practice Address - Phone:910-436-5000
Practice Address - Fax:910-436-7705
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1830111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085GRMedicaid
NC013FCOtherBCBS PROVIDER NO.
NC89085GRMedicaid
NC013FCOtherBCBS PROVIDER NO.