Provider Demographics
NPI:1609153345
Name:PROVIDENCE HEALTH CENTER
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:D
Authorized Official - Last Name:HYSER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-620-8856
Mailing Address - Street 1:6911 SHANNON WILLOW RD
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-1351
Mailing Address - Country:US
Mailing Address - Phone:704-800-7414
Mailing Address - Fax:704-817-3390
Practice Address - Street 1:6911 SHANNON WILLOW RD
Practice Address - Street 2:SUITE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-1351
Practice Address - Country:US
Practice Address - Phone:704-800-7414
Practice Address - Fax:704-817-3390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-09
Last Update Date:2011-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3825111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2458775Medicare PIN