MEDICARE: BIG WAVE CHIROPRACTIC L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	4216	SC

General Provider Information

NPI Number	:	1275069387
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BIG WAVE CHIROPRACTIC L.L.C.

Provider Business Mailing Address
First Line	:	3620 WALTON DR UNIT C4
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-6782
Country	:	US
Telephone Number	:	843-455-1453
Fax Number	:

Provider Business Practice Location Address
First Line	:	3620 WALTON DR UNIT C4
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-6782
Country	:	US
Telephone Number	:	843-455-1453
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	DR. JAMES KELLY WRIGHT
Credential	:	D.C.
Telephone Number	:	843-455-1453

Provider Enumeration Date	:	05/10/2017
Last Update Date	:	07/21/2022

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