Provider Demographics
NPI:1679787618
Name:THE UPSTATE CLINIC OF SPECIFIC CHIR
Entity type:Organization
Organization Name:THE UPSTATE CLINIC OF SPECIFIC CHIR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONICELLO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:864-855-3255
Mailing Address - Street 1:838 POWDERSVILLE RD
Mailing Address - Street 2:SUITE R
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-3703
Mailing Address - Country:US
Mailing Address - Phone:864-855-3255
Mailing Address - Fax:864-855-3254
Practice Address - Street 1:838 POWDERSVILLE RD
Practice Address - Street 2:SUITE R
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29642-3703
Practice Address - Country:US
Practice Address - Phone:864-855-3255
Practice Address - Fax:864-855-3254
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2941111N00000X
SC3243111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC8146Medicare PIN