Provider Demographics
NPI:1679809644
Name:EASTERN SHORE CHIROPRACTIC & SPORTS CLINIC, INC
Entity type:Organization
Organization Name:EASTERN SHORE CHIROPRACTIC & SPORTS CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:FISHER
Authorized Official - Last Name:SOUTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:225-274-5507
Mailing Address - Street 1:151 FLY CREEK AVENUE
Mailing Address - Street 2:SUITE 411
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-3843
Mailing Address - Country:US
Mailing Address - Phone:225-274-5507
Mailing Address - Fax:
Practice Address - Street 1:151 FLY CREEK AVENUE
Practice Address - Street 2:SUITE 411
Practice Address - City:FAIRHOPE
Practice Address - State:AL
Practice Address - Zip Code:36532-3843
Practice Address - Country:US
Practice Address - Phone:225-274-5507
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-27
Last Update Date:2009-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty