Healthcare Provider Details

I. General information

NPI: 1437195864
Provider Name (Legal Business Name): JEFFERSON CHIROPRACTIC CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 10/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7486 MARTINSBURG PIKE
SHEPHERDSTOWN WV
25443
US

IV. Provider business mailing address

7486 MARTINSBURG PIKE
SHEPHERDSTOWN WV
25443
US

V. Phone/Fax

Practice location:
  • Phone: 304-876-8200
  • Fax: 304-876-6826
Mailing address:
  • Phone: 304-876-8200
  • Fax: 304-876-6826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number644
License Number StateWV

VIII. Authorized Official

Name: BRIAN S. ERICKSON
Title or Position: PRESIDENT
Credential:
Phone: 304-876-8200