=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962068437
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARDINAL CHIROPRACTIC AND SPORTS RECOVERY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/10/2019
-----------------------------------------------------
Last Update Date | 05/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1710 WESTBROOK AVE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-270-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1710 WESTBROOK AVE
-----------------------------------------------------
City | BURLINGTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27215-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-270-3050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANDREW VAN HOEWYK
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 860-550-0798
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------