Provider Demographics
NPI:1437195864
Name:JEFFERSON CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:JEFFERSON CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:ERICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:304-876-8200
Mailing Address - Street 1:7486 MARTINSBURG PIKE
Mailing Address - Street 2:
Mailing Address - City:SHEPHERDSTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25443
Mailing Address - Country:US
Mailing Address - Phone:304-876-8200
Mailing Address - Fax:304-876-6826
Practice Address - Street 1:7486 MARTINSBURG PIKE
Practice Address - Street 2:
Practice Address - City:SHEPHERDSTOWN
Practice Address - State:WV
Practice Address - Zip Code:25443
Practice Address - Country:US
Practice Address - Phone:304-876-8200
Practice Address - Fax:304-876-6826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV644111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0132165000Medicaid
WVU64278Medicare UPIN
9361781Medicare PIN