Provider Demographics
NPI:1871511766
Name:TEGA CAY CHIROPRACTIC - SPORTS INJURY CLINIC INC
Entity Type:Organization
Organization Name:TEGA CAY CHIROPRACTIC - SPORTS INJURY CLINIC INC
Other - Org Name:RANDALL J CONGER DC
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONGER
Authorized Official - Suffix:
Authorized Official - Credentials:DC CCSP
Authorized Official - Phone:803-802-5322
Mailing Address - Street 1:101 STONE VILLAGE DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708
Mailing Address - Country:US
Mailing Address - Phone:803-802-5322
Mailing Address - Fax:803-802-5665
Practice Address - Street 1:101 STONE VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708
Practice Address - Country:US
Practice Address - Phone:803-802-5322
Practice Address - Fax:803-802-5665
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2295111N00000X
NC1915111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1916Medicaid
SCCH1916Medicaid