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General NPI Number Information
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NPI Number | 1134153448
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Entity Type | Organization
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Legal Business Name | GREAT BRIDGE CHIROPRACTIC PHYSICIAN PC
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Dates
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Enumeration Date | 07/10/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 676 KINGSBOROUGH SQ SUITE C
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City | CHESAPEAKE
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State | VA
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Zip | 23320-4954
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Country | US
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Telephone | 757-549-2273
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Fax | 757-548-1980
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Provider Business Mailing Address
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Address Line | 676 KINGSBOROUGH SQ SUITE C
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City | CHESAPEAKE
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State | VA
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Zip | 23320-4954
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Country | US
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Telephone | 757-549-2273
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Fax | 757-548-1980
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Authorized Official
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Title or Position | OWNER/PRESIDENT
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Name | DR. DARRYL EVAN MACDOWALL
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Credential | DC
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Telephone | 757-549-2273
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 0104001072
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License Number State | VA
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