=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639603061
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POLARIS HEALTH, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/12/2017
-----------------------------------------------------
Last Update Date | 04/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11025 MONROE RD STE G
-----------------------------------------------------
City | MATTHEWS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28105-6556
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-845-5150
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6608 S ROCKY RIVER RD
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28112-9318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-457-6990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRINCIPLE
-----------------------------------------------------
Name | MRS. ELIZABETH ANNE HARRILL
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 864-457-6990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4244
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------