Provider Demographics
NPI:1326415670
Name:OLD BRIDGE CHIROPRACTIC, PLLC
Entity Type:Organization
Organization Name:OLD BRIDGE CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:SETH
Authorized Official - Middle Name:MYER
Authorized Official - Last Name:DELETETSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:207-590-9756
Mailing Address - Street 1:4022 OLD BRIDGE RD SE STE D
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-9286
Mailing Address - Country:US
Mailing Address - Phone:910-363-4139
Mailing Address - Fax:
Practice Address - Street 1:4022 OLD BRIDGE RD SE STE D
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-9286
Practice Address - Country:US
Practice Address - Phone:910-363-4139
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4572111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty