Healthcare Provider Details

I. General information

NPI: 1891893798
Provider Name (Legal Business Name): LAKE WYLIE FAMILY CHIROPRACTIC INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 09/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

244 LATITUDE LN SUITE 104
CLOVER SC
29710-8124
US

IV. Provider business mailing address

244 LATITUDE LN SUITE 104
CLOVER SC
29710-8124
US

V. Phone/Fax

Practice location:
  • Phone: 803-831-6500
  • Fax: 803-831-6383
Mailing address:
  • Phone: 803-831-6500
  • Fax: 803-831-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2361
License Number StateSC

VIII. Authorized Official

Name: DR. ALAN D HARTLEY
Title or Position: PRESIDENT
Credential: PH.D., DC
Phone: 803-831-6500