=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902258791
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARMINES CHIROPRACTIC LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/06/2016
-----------------------------------------------------
Last Update Date | 07/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 837 FIRST COLONIAL RD SUITE A
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-6195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-222-1764
-----------------------------------------------------
Fax | 757-222-1765
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 837 FIRST COLONIAL RD SUITE A
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23451-6195
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-222-1764
-----------------------------------------------------
Fax | 757-222-1765
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. CRYSTAL CARMINES
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 757-222-1764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104557283
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------