=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710074174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SURFSIDE CHIROPRACTIC CENTER INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3103 HWY 17 SOUTH
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29576-7629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-357-3800
-----------------------------------------------------
Fax | 843-357-3117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3103 HWY 17 SOUTH
-----------------------------------------------------
City | GARDEN CITY
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29576-7629
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-357-3800
-----------------------------------------------------
Fax | 843-357-3117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DR OF CHIROPRACTIC
-----------------------------------------------------
Name | DR. LARRY EDWARD SIMON
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 843-357-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1332
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------