Healthcare Provider Details

I. General information

NPI: 1487803292
Provider Name (Legal Business Name): WISE CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 01/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 W MAIN ST SUITE F
WISE VA
24293-6905
US

IV. Provider business mailing address

517 W MAIN ST SUITE F
WISE VA
24293-6905
US

V. Phone/Fax

Practice location:
  • Phone: 276-328-2260
  • Fax:
Mailing address:
  • Phone: 276-328-2260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556639
License Number StateVA

VIII. Authorized Official

Name: OWEN ELWOOD POWERS
Title or Position: PRESIDENT
Credential: DC
Phone: 276-328-2260