Healthcare Provider Details

I. General information

NPI: 1114248739
Provider Name (Legal Business Name): QUATTLEBAUM CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 DORCHESTER MANOR BLVD
NORTH CHARLESTON SC
29420-8108
US

IV. Provider business mailing address

283 DORCHESTER MANOR BLVD
NORTH CHARLESTON SC
29420-8108
US

V. Phone/Fax

Practice location:
  • Phone: 843-552-8000
  • Fax: 843-552-0093
Mailing address:
  • Phone: 843-552-8000
  • Fax: 843-552-0093

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number3095
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3095
License Number StateSC

VIII. Authorized Official

Name: DR. BRIAN QUATTLEBAUM
Title or Position: OWNER
Credential: DC
Phone: 843-552-8000