Provider Demographics
NPI:1700906740
Name:MAIN STREET CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:MAIN STREET CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DUNCAN
Authorized Official - Middle Name:CHURCH
Authorized Official - Last Name:DEVOLLD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-249-6543
Mailing Address - Street 1:301 MAIN ST # B
Mailing Address - Street 2:
Mailing Address - City:NORTH MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29582-3022
Mailing Address - Country:US
Mailing Address - Phone:843-249-5432
Mailing Address - Fax:843-280-0837
Practice Address - Street 1:301 MAIN ST # B
Practice Address - Street 2:
Practice Address - City:NORTH MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29582-3022
Practice Address - Country:US
Practice Address - Phone:843-249-5432
Practice Address - Fax:843-280-0837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-31
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1308111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH1308Medicaid
SCU115480281Medicare ID - Type Unspecified