Provider Demographics
NPI:1801963129
Name:RISSEW, CHARLES ALAN JR (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ALAN
Last Name:RISSEW
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:8600 SAM FURR RD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28078-6138
Mailing Address - Country:US
Mailing Address - Phone:704-892-2282
Mailing Address - Fax:704-892-2630
Practice Address - Street 1:8600 SAM FURR RD
Practice Address - Street 2:SUITE 180
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-6138
Practice Address - Country:US
Practice Address - Phone:704-892-2282
Practice Address - Fax:704-892-2630
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2878111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89085EUMedicaid
NC085EUOtherBCBS ID NUMBER
NC89085EUMedicaid