Healthcare Provider Details

I. General information

NPI: 1679611578
Provider Name (Legal Business Name): CENTRAL AVENUE HEALTHWORKS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2007
Last Update Date: 07/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 CENTRAL AVE
SUMMERVILLE SC
29483-3713
US

IV. Provider business mailing address

713 CENTRAL AVE
SUMMERVILLE SC
29483-3713
US

V. Phone/Fax

Practice location:
  • Phone: 843-821-8787
  • Fax: 843-821-8799
Mailing address:
  • Phone: 843-821-8787
  • Fax: 843-821-8799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number909
License Number StateSC

VIII. Authorized Official

Name: DR. GREGORY S COOPER
Title or Position: PRESIDENT
Credential: DC
Phone: 843-821-8787