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General NPI Number Information
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NPI Number | 1679560742
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Entity Type | Organization
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Legal Business Name | THREE FOUNTAINS CHIROPRACTIC, INC.
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Dates
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Enumeration Date | 10/04/2005
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Last Update Date | 08/24/2007
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Provider Practice Location Address
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Address Line | 1926 S LAKE DR
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City | LEXINGTON
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State | SC
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Zip | 29073-8282
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Country | US
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Telephone | 803-808-1897
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 84428 1926 SOUTH LAKE DRIVE
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City | LEXINGTON
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State | SC
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Zip | 29073-0008
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Country | US
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Telephone | 803-808-1897
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Fax | 803-808-1297
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DAVID R GOOLDY
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Credential | DC
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Telephone | 803-808-1897
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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 | 2108
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License Number State | SC
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