Provider Demographics
NPI:1326360371
Name:THE WELLNESS CENTER OF THE OUTER BANKS INC
Entity Type:Organization
Organization Name:THE WELLNESS CENTER OF THE OUTER BANKS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:252-261-5424
Mailing Address - Street 1:PO BOX 262
Mailing Address - Street 2:3723 N. CROATAN HWY
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-0262
Mailing Address - Country:US
Mailing Address - Phone:252-261-5424
Mailing Address - Fax:252-261-5324
Practice Address - Street 1:3723 N. CROATAN HWY
Practice Address - Street 2:UNIT G
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949
Practice Address - Country:US
Practice Address - Phone:252-261-5424
Practice Address - Fax:252-261-5324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-18
Last Update Date:2010-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1672111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890844AMedicaid
NC0844AOtherBLUE CROSS BLUE SHIELD OF NC
NC2447904Medicare PIN
NCU41649Medicare UPIN