MEDICARE: DICKSON CLINIC OF CHIROPRACTIC PA

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	1245	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	08351	OTHER	NC	BLUE CROSS/BLUE SHIELD

General Provider Information

NPI Number	:	1922106863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DICKSON CLINIC OF CHIROPRACTIC PA

Provider Business Mailing Address
First Line	:	2909 REYNOLDA RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-3048
Country	:	US
Telephone Number	:	336-777-8450
Fax Number	:	336-777-8435

Provider Business Practice Location Address
First Line	:	2909 REYNOLDA RD
Second Line	:
City	:	WINSTON SALEM
State	:	NC
Zip	:	27106-3048
Country	:	US
Telephone Number	:	336-777-8450
Fax Number	:	336-777-8435

Authorized Official
Title or Position	:	OWNER
Name	:	DR. THOMAS A DICKSON
Credential	:	DC
Telephone Number	:	336-777-8540

Provider Enumeration Date	:	09/21/2006
Last Update Date	:	05/07/2008

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