Healthcare Provider Details

I. General information

NPI: 1477025393
Provider Name (Legal Business Name): EAST COAST ELITE CHIROPRACTIC PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2018
Last Update Date: 12/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N MAIN ST
BLACKSTONE VA
23824-1426
US

IV. Provider business mailing address

204 N MAIN ST
BLACKSTONE VA
23824-1426
US

V. Phone/Fax

Practice location:
  • Phone: 434-298-0707
  • Fax:
Mailing address:
  • Phone: 434-298-0707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: ROBY T MYERS
Title or Position: SOLE MBR
Credential: DC
Phone: 434-298-0707