Provider Demographics
NPI:1720455959
Name:PURE CHIROPRACTIC
Entity Type:Organization
Organization Name:PURE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:POKORNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-421-2562
Mailing Address - Street 1:3105 ROCK HILL CHURCH RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027-6703
Mailing Address - Country:US
Mailing Address - Phone:704-793-1329
Mailing Address - Fax:704-793-1392
Practice Address - Street 1:3105 ROCK HILL CHURCH RD
Practice Address - Street 2:SUITE 101
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027-6703
Practice Address - Country:US
Practice Address - Phone:704-793-1329
Practice Address - Fax:704-793-1392
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-24
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1720455959Medicaid
NC1720455959Medicaid