Provider Demographics
NPI:1376050732
Name:CHARLOTTE CHIROPRACTIC AND REHAB
Entity Type:Organization
Organization Name:CHARLOTTE CHIROPRACTIC AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:MAUL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-543-4307
Mailing Address - Street 1:7810 BALLANTYNE COMMONS PKWY
Mailing Address - Street 2:101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277
Mailing Address - Country:US
Mailing Address - Phone:704-543-4307
Mailing Address - Fax:
Practice Address - Street 1:7810 BALLANTYNE COMMONS PKWY
Practice Address - Street 2:101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277
Practice Address - Country:US
Practice Address - Phone:704-543-4307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-08
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4327111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty