Provider Demographics
NPI:1164452926
Name:DEGRAAF CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:DEGRAAF CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER -CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:C
Authorized Official - Last Name:DEGRAAF
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-279-3360
Mailing Address - Street 1:244 EDGEFIELD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-2486
Mailing Address - Country:US
Mailing Address - Phone:803-279-3360
Mailing Address - Fax:803-279-9440
Practice Address - Street 1:244 EDGEFIELD RD
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-2486
Practice Address - Country:US
Practice Address - Phone:803-279-3360
Practice Address - Fax:803-279-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGCH119Medicaid
SC3911Medicare PIN