Provider Demographics
NPI:1710150016
Name:CHIROPRACTIC HEALTH AND WELLNESS CENTER, P. A.
Entity Type:Organization
Organization Name:CHIROPRACTIC HEALTH AND WELLNESS CENTER, P. A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:HENRY
Authorized Official - Last Name:FONKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-487-5010
Mailing Address - Street 1:5414 YADKIN RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303-3199
Mailing Address - Country:US
Mailing Address - Phone:910-487-5010
Mailing Address - Fax:910-487-3919
Practice Address - Street 1:5414 YADKIN RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-3199
Practice Address - Country:US
Practice Address - Phone:910-487-5010
Practice Address - Fax:910-487-3919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2691111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890836UMedicaid
NC0836UOtherBCBS
NC890836UMedicaid
NC2453349EMedicare PIN