Provider Demographics
NPI:1144605759
Name:CAROLINA SPORTS CLINIC-FORT MILL,LLC
Entity Type:Organization
Organization Name:CAROLINA SPORTS CLINIC-FORT MILL,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WEIST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:803-547-9800
Mailing Address - Street 1:985 MARKET ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6532
Mailing Address - Country:US
Mailing Address - Phone:803-547-9800
Mailing Address - Fax:803-547-9804
Practice Address - Street 1:985 MARKET ST
Practice Address - Street 2:SUITE 201
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6532
Practice Address - Country:US
Practice Address - Phone:704-449-6601
Practice Address - Fax:980-225-7914
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-24
Last Update Date:2015-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3905111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty