Provider Demographics
NPI:1710143854
Name:COMMONWEALTH CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:COMMONWEALTH CHIROPRACTIC CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:R
Authorized Official - Last Name:FONTEYNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:434-929-4999
Mailing Address - Street 1:3756 SOUTH AMHERST HIGHWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:24572
Mailing Address - Country:US
Mailing Address - Phone:434-929-4999
Mailing Address - Fax:434-929-4997
Practice Address - Street 1:3756 SOUTH AMHERST HIGHWAY
Practice Address - Street 2:SUITE 100
Practice Address - City:MADISON HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:24572
Practice Address - Country:US
Practice Address - Phone:434-929-4999
Practice Address - Fax:434-929-4997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-29
Last Update Date:2008-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA263552OtherANTHEM
VA2995862OtherCIGNA
VA350040203OtherRAILROAD MEDICARE
VA263552OtherANTHEM