Provider Demographics
NPI:1104018852
Name:WATEREE CHIROPRACTIC
Entity Type:Organization
Organization Name:WATEREE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DURHAM
Authorized Official - Middle Name:RUSSELL
Authorized Official - Last Name:MAPLES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-438-1177
Mailing Address - Street 1:PO BOX 248
Mailing Address - Street 2:
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-0248
Mailing Address - Country:US
Mailing Address - Phone:803-438-1177
Mailing Address - Fax:
Practice Address - Street 1:810 RIDGEWAY ROAD
Practice Address - Street 2:
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-0248
Practice Address - Country:US
Practice Address - Phone:803-438-1177
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1266111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty