Provider Demographics
NPI:1194005157
Name:SOUTHEAST SPORTS CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:SOUTHEAST SPORTS CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:E
Authorized Official - Last Name:RIDDLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-680-3704
Mailing Address - Street 1:115 SOUTHPORT RD
Mailing Address - Street 2:UNIT F
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29306-3813
Mailing Address - Country:US
Mailing Address - Phone:864-680-3704
Mailing Address - Fax:
Practice Address - Street 1:115 SOUTHPORT RD
Practice Address - Street 2:UNIT F
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29306-3813
Practice Address - Country:US
Practice Address - Phone:864-680-3704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3484111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty