Provider Demographics
NPI:1558790584
Name:ANDERSON SPINE & INJURY CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:ANDERSON SPINE & INJURY CHIROPRACTIC CENTER
Other - Org Name:WICKISER PHYSICAL MEDICINE
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:W
Authorized Official - Last Name:WICKISER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-226-8688
Mailing Address - Street 1:122 EAST WEST PARKWAY
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-1361
Mailing Address - Country:US
Mailing Address - Phone:864-226-8868
Mailing Address - Fax:864-226-8804
Practice Address - Street 1:122 EAST WEST PARKWAY
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1361
Practice Address - Country:US
Practice Address - Phone:864-226-8868
Practice Address - Fax:864-226-8804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
SC14773207R00000X
SC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7186150001Medicare NSC
SCD256Medicare PIN