=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346843489
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENHANCED LIVING-SIMPSONVILLE CHIROPRACTIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2020
-----------------------------------------------------
Last Update Date | 11/23/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 N MAIN ST
-----------------------------------------------------
City | SIMPSONVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29681-2310
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-848-0640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 140 SAGE CREEK WAY
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29650-0957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-848-0640
-----------------------------------------------------
Fax | 864-848-0646
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | NINA R KENNEDY
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 864-380-8804
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------