=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871802793
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIVERSITY SPINE CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2010
-----------------------------------------------------
Last Update Date | 09/27/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1357 BACONS BRIDGE RD
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29485-3335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 843-851-3364
-----------------------------------------------------
Fax | 843-851-0746
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 161 SPRING MEADOWS DR
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29485-8792
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN JOSEPH IANNACE
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 843-851-3364
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 1298
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------