=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013405265
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPRUCE PINE CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/24/2018
-----------------------------------------------------
Last Update Date | 04/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31 CROSS STREET SUITE 266
-----------------------------------------------------
City | SPRUCE PINE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28777
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-520-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 31 CROSS ST STE 266
-----------------------------------------------------
City | SPRUCE PINE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28777-6160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-520-1800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. JONATHAN QUINN WARD
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 828-520-1800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 4882
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------