Provider Demographics
NPI:1184844995
Name:NORTHERN NECK CHIROPRACTIC PC
Entity Type:Organization
Organization Name:NORTHERN NECK CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDIST
Authorized Official - Middle Name:JEEMS
Authorized Official - Last Name:LOVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-435-3333
Mailing Address - Street 1:351 S MAIN ST
Mailing Address - Street 2:P.O. BOX 1447
Mailing Address - City:KILMARNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22482-1447
Mailing Address - Country:US
Mailing Address - Phone:804-435-3333
Mailing Address - Fax:804-435-1933
Practice Address - Street 1:351 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:KILMARNOCK
Practice Address - State:VA
Practice Address - Zip Code:22482-1447
Practice Address - Country:US
Practice Address - Phone:804-435-3333
Practice Address - Fax:804-435-1933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2014-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000874111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT90813Medicare UPIN