Provider Demographics
NPI:1558582544
Name:IVY COMMONS FAMILY CHIROPRACTIC
Entity Type:Organization
Organization Name:IVY COMMONS FAMILY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:MEGHAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CUSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:434-817-3666
Mailing Address - Street 1:4422 IVY CMNS
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22903-7123
Mailing Address - Country:US
Mailing Address - Phone:434-817-3666
Mailing Address - Fax:434-293-0712
Practice Address - Street 1:4422 IVY CMNS
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-7123
Practice Address - Country:US
Practice Address - Phone:434-817-3666
Practice Address - Fax:434-293-0712
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:IVY COMMONS FAMILY CHIROPRACTIC PLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-01
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104002067111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAU81266Medicare UPIN
VA350001082Medicare ID - Type UnspecifiedPROVIDER #