Provider Demographics
NPI:1154482537
Name:WEAVER, GARY S (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:S
Last Name:WEAVER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9570 TWO NOTCH RD
Mailing Address - Street 2:STE1
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4308
Mailing Address - Country:US
Mailing Address - Phone:803-736-2200
Mailing Address - Fax:803-736-2201
Practice Address - Street 1:9570 TWO NOTCH RD
Practice Address - Street 2:STE1
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-4308
Practice Address - Country:US
Practice Address - Phone:803-736-2200
Practice Address - Fax:803-736-2201
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1037111N00000X, 111NS0005X, 111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered111N00000XChiropractic ProvidersChiropractor
Not Answered111NS0005XChiropractic ProvidersChiropractorSports Physician
Not Answered111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3023Medicare ID - Type Unspecified