Provider Demographics
NPI:1588843023
Name:BASIC ESSENTIALS SPINAL CARE CENTER
Entity Type:Organization
Organization Name:BASIC ESSENTIALS SPINAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WADE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:SPROVIERO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:273-236-3833
Mailing Address - Street 1:2744 GLENDALE RD
Mailing Address - Street 2:
Mailing Address - City:GALAX
Mailing Address - State:VA
Mailing Address - Zip Code:24333-5350
Mailing Address - Country:US
Mailing Address - Phone:276-236-3833
Mailing Address - Fax:276-236-9376
Practice Address - Street 1:2744 GLENDALE RD
Practice Address - Street 2:
Practice Address - City:GALAX
Practice Address - State:VA
Practice Address - Zip Code:24333-5350
Practice Address - Country:US
Practice Address - Phone:276-236-3833
Practice Address - Fax:276-236-9376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-01
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000891111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06671Medicare UPIN