=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609429281
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMBINED CHIROPRACTIC & ACUPUNCTURE, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2019
-----------------------------------------------------
Last Update Date | 10/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 115 COMMONS DR STE D
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-9264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-721-7009
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 115 COMMONS DR STE D
-----------------------------------------------------
City | MOORESVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28117-9264
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 980-444-0060
-----------------------------------------------------
Fax | 980-444-6860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MATTHEW JOHN ANTONELLI
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 980-444-0060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------