=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336463454
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALBEMARLE CHIROPRACTIC OFFICES, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2010
-----------------------------------------------------
Last Update Date | 03/18/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 W EHRINGHAUS ST
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-7049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-338-3206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 808 W EHRINGHAUS ST
-----------------------------------------------------
City | ELIZABETH CITY
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27909-7049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 252-338-3206
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | STEPHEN ROBERT VAN GIESEN
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 252-338-3206
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 1224
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------