MEDICARE: CROWN PLAZA CHIROPRACTIC, LLC

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	3121	SC

General Provider Information

NPI Number	:	1275720815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN PLAZA CHIROPRACTIC, LLC

Provider Business Mailing Address
First Line	:	3160 HIGHWAY 21
Second Line	:	SUITE 106
City	:	FORT MILL
State	:	SC
Zip	:	29715-8845
Country	:	US
Telephone Number	:	803-548-9091
Fax Number	:

Provider Business Practice Location Address
First Line	:	3160 HIGHWAY 21
Second Line	:	SUITE 106
City	:	FORT MILL
State	:	SC
Zip	:	29715-8845
Country	:	US
Telephone Number	:	803-548-9091
Fax Number	:

Authorized Official
Title or Position	:	OWNER/OPERATOR
Name	:	DR. SCOTTIE L. WILLIAMS
Credential	:	D.C.
Telephone Number	:	803-548-9091

Provider Enumeration Date	:	09/27/2007
Last Update Date	:	09/27/2007

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