Provider Demographics
NPI:1184058745
Name:SOUTHEAST FUNCTIONAL CHIROPRACTIC
Entity type:Organization
Organization Name:SOUTHEAST FUNCTIONAL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:CORBIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-848-5775
Mailing Address - Street 1:1802 US HIGHWAY 98
Mailing Address - Street 2:STE E
Mailing Address - City:DAPHNE
Mailing Address - State:AL
Mailing Address - Zip Code:36526-4861
Mailing Address - Country:US
Mailing Address - Phone:251-375-0012
Mailing Address - Fax:251-375-0011
Practice Address - Street 1:1802 US HIGHWAY 98
Practice Address - Street 2:STE E
Practice Address - City:DAPHNE
Practice Address - State:AL
Practice Address - Zip Code:36526-4861
Practice Address - Country:US
Practice Address - Phone:847-848-5775
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-30
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2403111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty