Healthcare Provider Details

I. General information

NPI: 1871854380
Provider Name (Legal Business Name): CAROLINA SPINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2012
Last Update Date: 04/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8451 CHARLOTTE HWY
INDIAN LAND SC
29707-7587
US

IV. Provider business mailing address

8451 CHARLOTTE HWY
INDIAN LAND SC
29707-7587
US

V. Phone/Fax

Practice location:
  • Phone: 803-548-8100
  • Fax: 803-548-8111
Mailing address:
  • Phone: 803-548-8100
  • Fax: 803-548-8111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3709
License Number StateSC

VIII. Authorized Official

Name: RYAN VALENCIC
Title or Position: OWNER
Credential: DC
Phone: 803-548-8100