Provider Demographics
NPI:1871892539
Name:UPSTATE HEALTH PROFESSIONALS,LLC
Entity type:Organization
Organization Name:UPSTATE HEALTH PROFESSIONALS,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:V
Authorized Official - Last Name:BRIDGES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-804-6612
Mailing Address - Street 1:2084 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-1425
Mailing Address - Country:US
Mailing Address - Phone:864-804-6612
Mailing Address - Fax:864-804-6613
Practice Address - Street 1:2084 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1425
Practice Address - Country:US
Practice Address - Phone:864-804-6612
Practice Address - Fax:864-804-6613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1490111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1490Medicaid
SCCH1490Medicaid