Healthcare Provider Details

I. General information

NPI: 1205978103
Provider Name (Legal Business Name): CRANBERRY SQUARE CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOX 562
S YARMOUTH MA
02664-0562
US

IV. Provider business mailing address

24 ROUTE 134 SUITE 3
SOUTH DENNIS MA
02660-3739
US

V. Phone/Fax

Practice location:
  • Phone: 508-394-1625
  • Fax:
Mailing address:
  • Phone: 508-394-1625
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2727
License Number StateMA

VIII. Authorized Official

Name: DR. WAYNE D HICKS
Title or Position: OWNER
Credential: DC
Phone: 508-394-1625