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General NPI Number Information
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NPI Number | 1497204101
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Entity Type | Organization
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Legal Business Name | BLUE RIDGE HEALTH AND SPINE, PLLC
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Dates
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Enumeration Date | 09/23/2016
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Last Update Date | 09/23/2016
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Provider Practice Location Address
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Address Line | 4911 BRIDGERS ROAD
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City | SHALLOTTE
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State | NC
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Zip | 28470-4474
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Country | US
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Telephone | 910-755-5483
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Fax | 910-755-5484
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Provider Business Mailing Address
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Address Line | PO BOX 1945
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City | SHALLOTTE
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State | NC
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Zip | 28459-1945
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Country | US
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Telephone | 910-755-5483
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Fax | 910-755-5484
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Authorized Official
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Title or Position | OWNER
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Name | MONIQUE JESSICA WEDDLE
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Credential | DC
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Telephone | 910-755-5483
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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 | 4536
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License Number State | NC
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