Provider Demographics
NPI:1174628416
Name:LAUREL PARK CHIROPRACTIC CENTER LLC
Entity Type:Organization
Organization Name:LAUREL PARK CHIROPRACTIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FREED
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:828-696-9090
Mailing Address - Street 1:212 S GROVE ST
Mailing Address - Street 2:SUITE D
Mailing Address - City:HENDERSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28792-4006
Mailing Address - Country:US
Mailing Address - Phone:828-696-9090
Mailing Address - Fax:
Practice Address - Street 1:212 S GROVE ST
Practice Address - Street 2:SUITE D
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28792-4006
Practice Address - Country:US
Practice Address - Phone:828-696-9090
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2136111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1139COtherBCBSNC PROVIDER ID
NC2433155Medicare ID - Type Unspecified
NCT84445Medicare UPIN