Provider Demographics
NPI:1295285872
Name:GREATER RALEIGH CHIROPRACTIC AND REHAB PLLC
Entity type:Organization
Organization Name:GREATER RALEIGH CHIROPRACTIC AND REHAB PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:ROISTACHER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:919-847-3959
Mailing Address - Street 1:8450 FALLS OF NEUSE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3549
Mailing Address - Country:US
Mailing Address - Phone:919-847-3959
Mailing Address - Fax:919-848-3948
Practice Address - Street 1:8450 FALLS OF NEUSE RD STE 100
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-3549
Practice Address - Country:US
Practice Address - Phone:919-847-3959
Practice Address - Fax:919-848-3948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-07
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC34992546111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPTAN84450281Medicare PIN