Provider Demographics
NPI:1881764082
Name:INNIS, DAVID MATHEW (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MATHEW
Last Name:INNIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9929 ALBEMARLE RD
Mailing Address - Street 2:STE 3B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3363
Mailing Address - Country:US
Mailing Address - Phone:704-545-7410
Mailing Address - Fax:704-545-9686
Practice Address - Street 1:9929 ALBEMARLE RD
Practice Address - Street 2:STE 3B
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227-3363
Practice Address - Country:US
Practice Address - Phone:704-545-7410
Practice Address - Fax:704-545-9686
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-08
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1394111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7908353Medicaid
NC244395Medicare ID - Type UnspecifiedPROVIDER #
NC7908353Medicaid