Provider Demographics
NPI:1548381742
Name:COMMUNITY CHIROPRACTIC PA
Entity Type:Organization
Organization Name:COMMUNITY CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:919-662-0044
Mailing Address - Street 1:260 HWY 70 WEST
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529
Mailing Address - Country:US
Mailing Address - Phone:919-662-0044
Mailing Address - Fax:919-662-1650
Practice Address - Street 1:260 HWY 70 W
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529
Practice Address - Country:US
Practice Address - Phone:919-662-0044
Practice Address - Fax:919-662-1650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-03
Last Update Date:2010-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3346111N00000X
NC1962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902415Medicaid
NC017AROtherBCBS
NC5902415Medicaid