Provider Demographics
NPI:1891893798
Name:LAKE WYLIE FAMILY CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:LAKE WYLIE FAMILY CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HARTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, DC
Authorized Official - Phone:803-831-6500
Mailing Address - Street 1:244 LATITUDE LN
Mailing Address - Street 2:SUITE 104
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-8124
Mailing Address - Country:US
Mailing Address - Phone:803-831-6500
Mailing Address - Fax:803-831-6383
Practice Address - Street 1:244 LATITUDE LN
Practice Address - Street 2:SUITE 104
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-8124
Practice Address - Country:US
Practice Address - Phone:803-831-6500
Practice Address - Fax:803-831-6383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2361111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2361Medicaid
SCGCH347Medicaid
SCU840598621Medicare ID - Type Unspecified
SCCH2361Medicaid