Healthcare Provider Details

I. General information

NPI: 1558790584
Provider Name (Legal Business Name): ANDERSON SPINE & INJURY CHIROPRACTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2013
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 EAST WEST PARKWAY
ANDERSON SC
29621-1361
US

IV. Provider business mailing address

122 EAST WEST PARKWAY
ANDERSON SC
29621-1361
US

V. Phone/Fax

Practice location:
  • Phone: 864-226-8868
  • Fax: 864-226-8804
Mailing address:
  • Phone: 864-226-8868
  • Fax: 864-226-8804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14773
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateSC

VIII. Authorized Official

Name: DR. CLAYTON W WICKISER
Title or Position: PRESIDENT
Credential: DC
Phone: 864-226-8688