Healthcare Provider Details

I. General information

NPI: 1891875779
Provider Name (Legal Business Name): LAURIE GROVINE D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10701 PARK RD SUITE G
CHARLOTTE NC
28210-8492
US

IV. Provider business mailing address

10701 PARK RD SUITE G
CHARLOTTE NC
28210-8492
US

V. Phone/Fax

Practice location:
  • Phone: 704-544-8844
  • Fax: 704-544-8631
Mailing address:
  • Phone: 704-544-8844
  • Fax: 704-544-8631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number2247
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: