Healthcare Provider Details

I. General information

NPI: 1780909457
Provider Name (Legal Business Name): FENTRESS CHIROPRACTIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 05/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 COMMERCIAL DR A
MOYOCK NC
27958-8746
US

IV. Provider business mailing address

112 COMMERCIAL DR A
MOYOCK NC
27958-8746
US

V. Phone/Fax

Practice location:
  • Phone: 252-435-6131
  • Fax: 252-435-6852
Mailing address:
  • Phone: 252-435-6131
  • Fax: 252-435-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3163
License Number StateNC

VIII. Authorized Official

Name: DR. MATTHEW WAYNE FENTRESS
Title or Position: PRESIDENT
Credential: D.C.
Phone: 252-435-6131