Provider Demographics
NPI: | 1730468919 |
---|---|
Name: | GASTONIA SPINE & SPORT, P.A. |
Entity Type: | Organization |
Organization Name: | GASTONIA SPINE & SPORT, P.A. |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER/PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | AARON |
Authorized Official - Middle Name: | JOSEPH |
Authorized Official - Last Name: | STUMP |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 704-990-8266 |
Mailing Address - Street 1: | PO BOX 550307 |
Mailing Address - Street 2: | |
Mailing Address - City: | GASTONIA |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28055-0307 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-990-8266 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1941 HOFFMAN RD STE 6 |
Practice Address - Street 2: | |
Practice Address - City: | GASTONIA |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28054-7524 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-990-8266 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-08-05 |
Last Update Date: | 2011-08-05 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 4142 | 111NS0005X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111NS0005X | Chiropractic Providers | Chiropractor | Sports Physician | Group - Single Specialty |