Healthcare Provider Details

I. General information

NPI: 1588073233
Provider Name (Legal Business Name): SOUTHEASTERN CHIROPRACTIC CENTER P C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2014
Last Update Date: 10/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6420 GARNERS FERRY RD
COLUMBIA SC
29209-1632
US

IV. Provider business mailing address

PO BOX 11596
COLUMBIA SC
29211-1596
US

V. Phone/Fax

Practice location:
  • Phone: 803-553-3368
  • Fax:
Mailing address:
  • Phone: 803-553-3368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1581
License Number StateSC

VIII. Authorized Official

Name: LEWIS RANDAL HINSON
Title or Position: OWNER
Credential: DC, CCSP
Phone: 803-553-3368