Provider Demographics
NPI:1982883450
Name:HICKORY CHIRO AND SPORTS REHAB CTR
Entity Type:Organization
Organization Name:HICKORY CHIRO AND SPORTS REHAB CTR
Other - Org Name:HICKORY CHIROPRACTIC AND SPORTS REHABILITATION CENTER PLLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:PETREE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:757-410-9550
Mailing Address - Street 1:676 BATTLEFIELD BLVD N
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-0306
Mailing Address - Country:US
Mailing Address - Phone:757-410-9550
Mailing Address - Fax:757-410-9506
Practice Address - Street 1:676 BATTLEFIELD BLVD N
Practice Address - Street 2:SUITE A
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-0306
Practice Address - Country:US
Practice Address - Phone:757-410-9550
Practice Address - Fax:757-410-9506
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556563111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty