Provider Demographics
NPI:1679196919
Name:PETREY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:PETREY CHIROPRACTIC, LLC
Other - Org Name:SCHILLINGER ROAD CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:DARRELL
Authorized Official - Last Name:PETREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:251-635-1224
Mailing Address - Street 1:1516 SCHILLINGER ROAD SOUTH
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36695
Mailing Address - Country:US
Mailing Address - Phone:251-635-1224
Mailing Address - Fax:251-635-0911
Practice Address - Street 1:1516 SCHILLINGER ROAD SOUTH
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36695
Practice Address - Country:US
Practice Address - Phone:251-635-1224
Practice Address - Fax:251-635-0911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-21
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I350926Medicaid