Provider Demographics
NPI:1912459769
Name:VINTAGE CHIROPRACTIC
Entity Type:Organization
Organization Name:VINTAGE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GLORIA
Authorized Official - Middle Name:KIRSENA
Authorized Official - Last Name:STONE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:302-363-8758
Mailing Address - Street 1:2305 W 12TH ST
Mailing Address - Street 2:APT 2
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-2609
Mailing Address - Country:US
Mailing Address - Phone:302-363-8758
Mailing Address - Fax:
Practice Address - Street 1:2305 W 12TH ST
Practice Address - Street 2:APT 2
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-2609
Practice Address - Country:US
Practice Address - Phone:302-363-8758
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-27
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000943111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty