Provider Demographics
NPI:1972673291
Name:WYNNE CHIROPRACTIC CTR PA
Entity Type:Organization
Organization Name:WYNNE CHIROPRACTIC CTR PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:WYNNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-799-2225
Mailing Address - Street 1:3420A WRIGHTSVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4118
Mailing Address - Country:US
Mailing Address - Phone:910-799-2225
Mailing Address - Fax:910-799-6612
Practice Address - Street 1:3420A WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-4118
Practice Address - Country:US
Practice Address - Phone:910-799-2225
Practice Address - Fax:910-799-6612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08946OtherBCBS
NC8908946Medicaid
=========OtherTAX ID
NC244602BMedicare ID - Type Unspecified