Provider Demographics
NPI:1013608793
Name:MEDINA, LUIS FERNANDO (DC)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:FERNANDO
Last Name:MEDINA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1308 LORNA ST UNIT 308
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-5283
Mailing Address - Country:US
Mailing Address - Phone:954-670-6695
Mailing Address - Fax:
Practice Address - Street 1:1308 LORNA ST UNIT 308
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-5283
Practice Address - Country:US
Practice Address - Phone:954-670-6695
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5622111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor