Provider Demographics
NPI: | 1922310754 |
---|---|
Name: | PARK ROAD HEALTH AND WELLNESS INC |
Entity Type: | Organization |
Organization Name: | PARK ROAD HEALTH AND WELLNESS INC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | JEREMY |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | HOZJAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DC |
Authorized Official - Phone: | 704-523-2367 |
Mailing Address - Street 1: | 4312 PARK RD |
Mailing Address - Street 2: | |
Mailing Address - City: | CHARLOTTE |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28209-2271 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 704-523-2367 |
Mailing Address - Fax: | 704-523-9937 |
Practice Address - Street 1: | 4312 PARK RD |
Practice Address - Street 2: | |
Practice Address - City: | CHARLOTTE |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28209-2271 |
Practice Address - Country: | US |
Practice Address - Phone: | 704-523-2367 |
Practice Address - Fax: | 704-523-9937 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2010-07-09 |
Last Update Date: | 2010-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 4049 | 111N00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 111N00000X | Chiropractic Providers | Chiropractor | Group - Single Specialty |