Provider Demographics
NPI:1962484543
Name:RAVENSCROFT 58 INC
Entity Type:Organization
Organization Name:RAVENSCROFT 58 INC
Other - Org Name:HAYWOOD CHIROPRACTIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:SR
Authorized Official - Credentials:DC
Authorized Official - Phone:828-456-5700
Mailing Address - Street 1:136 WAYNESVILLE PLAZA
Mailing Address - Street 2:STE 1
Mailing Address - City:WAYNESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28786
Mailing Address - Country:US
Mailing Address - Phone:828-456-5700
Mailing Address - Fax:828-456-5728
Practice Address - Street 1:136 WAYNESVILLE PLAZA
Practice Address - Street 2:STE 1
Practice Address - City:WAYNESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28786
Practice Address - Country:US
Practice Address - Phone:828-456-5700
Practice Address - Fax:828-456-5728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-18
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1700111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890882FMedicaid
T18725Medicare UPIN
NC2334567Medicare ID - Type Unspecified