Provider Demographics
NPI:1972677524
Name:MOUNTAIN ISLAND CHIROPRACTIC
Entity Type:Organization
Organization Name:MOUNTAIN ISLAND CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:KUEBLER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:704-394-8556
Mailing Address - Street 1:10917 BLACK DOG LANE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28214
Mailing Address - Country:US
Mailing Address - Phone:704-394-8556
Mailing Address - Fax:
Practice Address - Street 1:10917 BLACK DOG LANE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28214
Practice Address - Country:US
Practice Address - Phone:704-394-8556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-17
Last Update Date:2008-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3183111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085N8Medicaid
NC2456832Medicare ID - Type Unspecified