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General NPI Number Information
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NPI Number | 1932584067
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Entity Type | Organization
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Legal Business Name | I HEART MY SPINE LLC
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Dates
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Enumeration Date | 07/30/2015
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Last Update Date | 07/30/2015
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Provider Practice Location Address
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Address Line | 4230 EAST TENTH STREET SUITE G
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City | GREENVILLE
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State | NC
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Zip | 27858-0838
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Country | US
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Telephone | 252-758-7583
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Fax | 252-624-0729
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Provider Business Mailing Address
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Address Line | 4230 E 10TH STREET SUITE G
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City | GREENVILLE
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State | NC
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Zip | 27858
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Country | US
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Telephone | 252-758-7583
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Fax | 252-624-0729
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Authorized Official
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Title or Position | DOCTOR/CHIROPRACTOR
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Name | DR. BRET MICHAEL WICKSTROM
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Credential | DC
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Telephone | 252-758-7583
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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 | 4026
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License Number State | NC
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