Provider Demographics
NPI:1558462887
Name:PELLICANI, RONALD J (DC)
Entity Type:Individual
Prefix:DR
First Name:RONALD
Middle Name:J
Last Name:PELLICANI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4016 RIVER OAKS DR # 149
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-6673
Mailing Address - Country:US
Mailing Address - Phone:843-236-2200
Mailing Address - Fax:
Practice Address - Street 1:568 GEORGE BISHOP PKWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-7339
Practice Address - Country:US
Practice Address - Phone:843-236-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1610111N00000X
SC3616111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1610082Medicaid
MA994529OtherNETWORK HEALTH PLAN
SCCH3616Medicaid
MAY36167OtherBC/BS OF MA
MA181432OtherAETNA
MA0014298OtherNEIGHBORHOOD HEALTH PLAN
MA1610082Medicaid