Provider Demographics
NPI:1346304532
Name:DAVIS CHIROPRACTIC OF MYRTLE BEACH, INC.
Entity Type:Organization
Organization Name:DAVIS CHIROPRACTIC OF MYRTLE BEACH, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFERSON
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-357-9495
Mailing Address - Street 1:12307 HIGHWAY 707
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-9740
Mailing Address - Country:US
Mailing Address - Phone:843-357-9495
Mailing Address - Fax:843-357-9440
Practice Address - Street 1:12307 HIGHWAY 707
Practice Address - Street 2:
Practice Address - City:MURRELLS INLET
Practice Address - State:SC
Practice Address - Zip Code:29576-9740
Practice Address - Country:US
Practice Address - Phone:843-357-9495
Practice Address - Fax:843-357-9440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2482111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2482Medicaid
SCU80958-4584Medicare UPIN
SCCH2482Medicaid