Provider Demographics
NPI:1407039183
Name:RIVER LANDING CHIROPRACTIC, INC
Entity Type:Organization
Organization Name:RIVER LANDING CHIROPRACTIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:843-971-8234
Mailing Address - Street 1:130 RIVER LANDING DR
Mailing Address - Street 2:12 D
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29492-7440
Mailing Address - Country:US
Mailing Address - Phone:843-971-8234
Mailing Address - Fax:
Practice Address - Street 1:130 RIVER LANDING DR
Practice Address - Street 2:12 D
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29492-7440
Practice Address - Country:US
Practice Address - Phone:843-971-8234
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2653111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7776Medicare PIN