Provider Demographics
NPI:1083882054
Name:ADVANCED CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:ADVANCED CHIROPRACTIC CENTER
Other - Org Name:ADVANCED CHIROPRACTIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:W
Authorized Official - Last Name:JORDAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-545-1396
Mailing Address - Street 1:POST OFFICE BOX 958
Mailing Address - Street 2:ADVANCED CHIROPRACTIC CENTER
Mailing Address - City:GEORGETOWN
Mailing Address - State:SC
Mailing Address - Zip Code:29440
Mailing Address - Country:US
Mailing Address - Phone:843-545-1396
Mailing Address - Fax:843-527-8353
Practice Address - Street 1:705 NORTH FRASER STREET
Practice Address - Street 2:ADVANCED CHIROPRACTIC CENTER
Practice Address - City:GEORGETOWN
Practice Address - State:SC
Practice Address - Zip Code:29440
Practice Address - Country:US
Practice Address - Phone:843-545-1396
Practice Address - Fax:843-527-8353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3056111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH507OtherMEDICAID GRP #
SCCH3056Medicaid
SCCH3056Medicaid