Provider Demographics
NPI:1932372521
Name:KERNERSVILLE CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:KERNERSVILLE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARIAN
Authorized Official - Middle Name:JUSTIN
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:336-996-2462
Mailing Address - Street 1:PO BOX 707
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27285-0707
Mailing Address - Country:US
Mailing Address - Phone:336-996-2462
Mailing Address - Fax:336-996-9878
Practice Address - Street 1:127 N MAIN ST
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-2815
Practice Address - Country:US
Practice Address - Phone:336-996-2462
Practice Address - Fax:336-996-9878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1999111N00000X
NC3796111N00000X
NC111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5908470Medicaid
NC890879BMedicaid
NC2448242OtherMEDICARE NUMBER
NC2456015OtherMEDICARE NUMBER
NC2448242Medicare PIN
NC2448242OtherMEDICARE NUMBER