Provider Demographics
NPI:1407832637
Name:KEITH CLINIC OF CHIROPRACTIC, P.A.
Entity Type:Organization
Organization Name:KEITH CLINIC OF CHIROPRACTIC, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FLETCHER
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:KEITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-392-1338
Mailing Address - Street 1:4016 TRIANGLE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-2828
Mailing Address - Country:US
Mailing Address - Phone:704-392-1338
Mailing Address - Fax:704-392-8156
Practice Address - Street 1:4016 TRIANGLE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-2828
Practice Address - Country:US
Practice Address - Phone:704-392-1338
Practice Address - Fax:704-392-8156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-20
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908428Medicaid
NC5900583Medicaid
NC8908428Medicaid