Provider Demographics
NPI:1922106863
Name:DICKSON CLINIC OF CHIROPRACTIC PA
Entity Type:Organization
Organization Name:DICKSON CLINIC OF CHIROPRACTIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:DICKSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:336-777-8540
Mailing Address - Street 1:2909 REYNOLDA RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3048
Mailing Address - Country:US
Mailing Address - Phone:336-777-8450
Mailing Address - Fax:336-777-8435
Practice Address - Street 1:2909 REYNOLDA RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3048
Practice Address - Country:US
Practice Address - Phone:336-777-8450
Practice Address - Fax:336-777-8435
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1245111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8908351Medicaid
NC08351OtherBLUE CROSS/BLUE SHIELD
NC244366Medicare ID - Type UnspecifiedMEDICARE
NCT64414Medicare UPIN