Provider Demographics
NPI:1477638609
Name:MYRTLE GROVE CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:MYRTLE GROVE CHIROPRACTIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARGIE
Authorized Official - Middle Name:BAUM
Authorized Official - Last Name:ANNIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-395-5664
Mailing Address - Street 1:5552 F CAROLINA BEACH ROAD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2648
Mailing Address - Country:US
Mailing Address - Phone:910-395-5664
Mailing Address - Fax:910-395-5625
Practice Address - Street 1:5552 CAROLINA BEACH RD
Practice Address - Street 2:SUITE F
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2787
Practice Address - Country:US
Practice Address - Phone:910-395-5664
Practice Address - Fax:910-395-5625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-26
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790185GMedicaid
NC0185GOtherBCBS
NC1477638609Medicare UPIN