Healthcare Provider Details

I. General information

NPI: 1780164947
Provider Name (Legal Business Name): ISLAND CHIROPRACTIC CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2018
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6295 TEAL LN
CHINCOTEAGUE ISLAND VA
23336-2207
US

IV. Provider business mailing address

6500 LEONARD LN
CHINCOTEAGUE ISLAND VA
23336-1334
US

V. Phone/Fax

Practice location:
  • Phone: 321-439-7265
  • Fax:
Mailing address:
  • Phone: 321-439-7265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH9501
License Number StateFL

VIII. Authorized Official

Name: DR. RODEN C STEWART
Title or Position: OWNER
Credential: DC
Phone: 321-439-7265