Provider Demographics
NPI:1780909457
Name:FENTRESS CHIROPRACTIC, INC
Entity type:Organization
Organization Name:FENTRESS CHIROPRACTIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:FENTRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:252-435-6131
Mailing Address - Street 1:112 COMMERCIAL DR
Mailing Address - Street 2:A
Mailing Address - City:MOYOCK
Mailing Address - State:NC
Mailing Address - Zip Code:27958-8746
Mailing Address - Country:US
Mailing Address - Phone:252-435-6131
Mailing Address - Fax:252-435-6852
Practice Address - Street 1:112 COMMERCIAL DR
Practice Address - Street 2:A
Practice Address - City:MOYOCK
Practice Address - State:NC
Practice Address - Zip Code:27958-8746
Practice Address - Country:US
Practice Address - Phone:252-435-6131
Practice Address - Fax:252-435-6852
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-04-06
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3163261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center