Provider Demographics
NPI:1720158199
Name:WAKE FOREST CHIROPRACTIC, PA
Entity Type:Organization
Organization Name:WAKE FOREST CHIROPRACTIC, PA
Other - Org Name:WAKE FOREST CHIROPRACTIC, PA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:P
Authorized Official - Last Name:PHELAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:919-562-0302
Mailing Address - Street 1:851 WAKE FOREST BUSINESS PARK
Mailing Address - Street 2:STE E
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-7366
Mailing Address - Country:US
Mailing Address - Phone:919-562-0302
Mailing Address - Fax:919-569-9560
Practice Address - Street 1:851 WAKE FOREST BUSINESS PARK
Practice Address - Street 2:STE E
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-7366
Practice Address - Country:US
Practice Address - Phone:919-562-0302
Practice Address - Fax:919-569-9560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-09
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2222111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2107045OtherCIGNA HEALTHCARE
NC08871OtherCHIROPRACTIC NETWORK
NC613467OtherAMERICAN CHIROPRACTIC NET
NC8908871Medicaid
NCU48060Medicare UPIN
NC2449645AMedicare PIN