Provider Demographics
NPI:1255524922
Name:CAROLINA CLINIC OF CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:CAROLINA CLINIC OF CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GREG
Authorized Official - Middle Name:C
Authorized Official - Last Name:SHIRLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-236-6290
Mailing Address - Street 1:4201 CAROLINA EXCHANGE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-4394
Mailing Address - Country:US
Mailing Address - Phone:843-236-6290
Mailing Address - Fax:843-236-6309
Practice Address - Street 1:4201 CAROLINA EXCHANGE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4394
Practice Address - Country:US
Practice Address - Phone:843-236-6290
Practice Address - Fax:843-236-6309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-24
Last Update Date:2013-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2331111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2331Medicaid
SCGCH362Medicaid
SCU763120281Medicare PIN