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General NPI Number Information
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NPI Number | 1154638989
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Entity Type | Organization
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Legal Business Name | MAIN STREET BACK AND NECK, PC
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Dates
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Enumeration Date | 08/31/2010
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Last Update Date | 09/22/2010
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Provider Practice Location Address
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Address Line | 2101 MAIN ST STE B
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City | COLUMBIA
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State | SC
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Zip | 29201-2159
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Country | US
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Telephone | 803-256-1224
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Fax | 803-256-1226
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Provider Business Mailing Address
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Address Line | 2101 MAIN ST STE B
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City | COLUMBIA
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State | SC
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Zip | 29201-2159
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Country | US
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Telephone | 803-256-1224
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Fax | 803-256-1226
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Authorized Official
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Title or Position | CHIROPRACTOR
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Name | LUKE YOUNG
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Credential |
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Telephone | 803-256-1224
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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 |
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License Number State |
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