Provider Demographics
NPI:1639369929
Name:PROSSER, RICHARD WISE (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:WISE
Last Name:PROSSER
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:PO BOX 16411
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28297-6411
Mailing Address - Country:US
Mailing Address - Phone:704-376-8666
Mailing Address - Fax:
Practice Address - Street 1:845 CHURCH ST N
Practice Address - Street 2:SUIE 210
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4300
Practice Address - Country:US
Practice Address - Phone:704-376-8666
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1405111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC244390BMedicare PIN