Provider Demographics
NPI:1225227796
Name:WALRAVEN CHIROPRACTIC
Entity Type:Organization
Organization Name:WALRAVEN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR
Authorized Official - Prefix:DR
Authorized Official - First Name:DARCEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALRAVEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-334-3761
Mailing Address - Street 1:10214 CHESTNUT PLAZA DR
Mailing Address - Street 2:SUITE 190
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8970
Mailing Address - Country:US
Mailing Address - Phone:260-625-6660
Mailing Address - Fax:260-625-6661
Practice Address - Street 1:3010 MONROE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-7532
Practice Address - Country:US
Practice Address - Phone:704-334-3761
Practice Address - Fax:704-334-3763
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3275111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908612Medicaid
NC89085UHMedicaid
NC2457657Medicare PIN
NC2456014Medicare PIN
NC2337821Medicare PIN