MEDICARE: STATEN CHIROPRACTIC AND WELLNESS CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	3133	NC

General Provider Information

NPI Number	:	1891958070
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATEN CHIROPRACTIC AND WELLNESS CENTER

Provider Business Mailing Address
First Line	:	5110 PARK RD
Second Line	:	SUITE 2A
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3699
Country	:	US
Telephone Number	:	704-561-0085
Fax Number	:	704-561-0785

Provider Business Practice Location Address
First Line	:	5110 PARK RD
Second Line	:	SUITE 2A
City	:	CHARLOTTE
State	:	NC
Zip	:	28209-3699
Country	:	US
Telephone Number	:	704-771-6092
Fax Number	:

Authorized Official
Title or Position	:	CHIROPRACTIC PHYSICIAN
Name	:	DR. TARA MARCELLA STATEN
Credential	:	DC
Telephone Number	:	704-561-0085

Provider Enumeration Date	:	07/08/2008
Last Update Date	:	06/18/2010

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