Provider Demographics
NPI:1831492628
Name:PUSTAVER CHIROPRACTIC CARE PA
Entity Type:Organization
Organization Name:PUSTAVER CHIROPRACTIC CARE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:TREATING CA
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-573-2400
Mailing Address - Street 1:4213 MATTHEWS MINT HILL RD
Mailing Address - Street 2:
Mailing Address - City:MATTHEWS
Mailing Address - State:NC
Mailing Address - Zip Code:28105-3634
Mailing Address - Country:US
Mailing Address - Phone:704-573-2400
Mailing Address - Fax:704-573-1070
Practice Address - Street 1:4213 MATTHEWS MINT HILL RD
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-3634
Practice Address - Country:US
Practice Address - Phone:704-573-2400
Practice Address - Fax:704-573-1070
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-16
Last Update Date:2011-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1509305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5900047Medicaid
NC5900047Medicaid