Provider Demographics
NPI:1114572518
Name:CAROLINA SPINE AND SPORT
Entity Type:Organization
Organization Name:CAROLINA SPINE AND SPORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEV'N
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-728-0201
Mailing Address - Street 1:1871 ASHLEY RIVER RD APT 4311
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-8724
Mailing Address - Country:US
Mailing Address - Phone:918-728-0201
Mailing Address - Fax:
Practice Address - Street 1:946 ORLEANS RD UNIT B10
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4839
Practice Address - Country:US
Practice Address - Phone:918-728-0201
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-03
Last Update Date:2019-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty