Provider Demographics
NPI:1801959580
Name:GOTRO CHIROPRACTIC OF INDIAN TRAIL
Entity type:Organization
Organization Name:GOTRO CHIROPRACTIC OF INDIAN TRAIL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HUGH
Authorized Official - Middle Name:CHARLES
Authorized Official - Last Name:GOTRO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:704-882-0192
Mailing Address - Street 1:13803 INDEPENDENCE BLVD STE E
Mailing Address - Street 2:
Mailing Address - City:INDIAN TRAIL
Mailing Address - State:NC
Mailing Address - Zip Code:28079-7680
Mailing Address - Country:US
Mailing Address - Phone:704-882-0192
Mailing Address - Fax:704-882-0612
Practice Address - Street 1:13803 INDEPENDENCE BLVD STE E
Practice Address - Street 2:
Practice Address - City:INDIAN TRAIL
Practice Address - State:NC
Practice Address - Zip Code:28079-7680
Practice Address - Country:US
Practice Address - Phone:704-882-0192
Practice Address - Fax:704-882-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2080111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890253KMedicaid
NC890253KMedicaid