Provider Demographics
NPI:1932292471
Name:AMERICAN FAMILY SPINE AND HEALTH LLC
Entity Type:Organization
Organization Name:AMERICAN FAMILY SPINE AND HEALTH LLC
Other - Org Name:AMERICAN FAMILY CHIROPRATIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-792-2700
Mailing Address - Street 1:3630 POPULAR TENT RD
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027
Mailing Address - Country:US
Mailing Address - Phone:704-792-2700
Mailing Address - Fax:704-792-2705
Practice Address - Street 1:3630 POPULAR TENT RD
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027
Practice Address - Country:US
Practice Address - Phone:704-792-2700
Practice Address - Fax:704-792-2705
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2391111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890825NMedicaid
U66366Medicare UPIN
NC890825NMedicare ID - Type Unspecified