Provider Demographics
NPI:1437691656
Name:LAKE WYLIE WELLNESS & CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:LAKE WYLIE WELLNESS & CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:G
Authorized Official - Last Name:REDDING
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:803-701-7077
Mailing Address - Street 1:4543 CHARLOTTE HWY
Mailing Address - Street 2:STE. 9
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-7073
Mailing Address - Country:US
Mailing Address - Phone:803-701-7077
Mailing Address - Fax:
Practice Address - Street 1:4543 CHARLOTTE HWY
Practice Address - Street 2:STE. 9
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-7073
Practice Address - Country:US
Practice Address - Phone:803-701-7077
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-07
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4080111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY14503BMedicare PIN