Provider Demographics
NPI:1982829701
Name:SOUTHERN CHIROPRACTIC
Entity Type:Organization
Organization Name:SOUTHERN CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFREDO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLEJO
Authorized Official - Suffix:III
Authorized Official - Credentials:DC
Authorized Official - Phone:803-269-2383
Mailing Address - Street 1:229 IVY HILL CT
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-8096
Mailing Address - Country:US
Mailing Address - Phone:803-269-2383
Mailing Address - Fax:
Practice Address - Street 1:221 COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-2611
Practice Address - Country:US
Practice Address - Phone:803-356-2870
Practice Address - Fax:803-356-2872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2715111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2715Medicaid