Provider Demographics
NPI:1366623142
Name:POQUOSON CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:POQUOSON CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCEWEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-868-7709
Mailing Address - Street 1:370A WYTHE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:POQUOSON
Mailing Address - State:VA
Mailing Address - Zip Code:23662-1926
Mailing Address - Country:US
Mailing Address - Phone:757-868-7709
Mailing Address - Fax:
Practice Address - Street 1:370A WYTHE CREEK RD
Practice Address - Street 2:
Practice Address - City:POQUOSON
Practice Address - State:VA
Practice Address - Zip Code:23662-1926
Practice Address - Country:US
Practice Address - Phone:757-868-7709
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-20
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001735111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC05259Medicare PIN