=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922340447
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETTY CHIROPRACTIC, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2013
-----------------------------------------------------
Last Update Date | 03/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1295 OLD US 1 SUITE F
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-246-2099
-----------------------------------------------------
Fax | 910-246-2098
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1295 OLD US 1 SUITE F
-----------------------------------------------------
City | SOUTHERN PINES
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28387
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-246-2099
-----------------------------------------------------
Fax | 910-246-2098
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN ADAM PETTY
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 704-214-2020
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 4185
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------