1790845824 NPI number — SPINE CARE CHIROPRACTIC CENTER, P.C.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790845824 NPI number — SPINE CARE CHIROPRACTIC CENTER, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPINE CARE CHIROPRACTIC CENTER, P.C.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790845824
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/02/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
130 JOHN FRANK WARD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCDONOUGH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30253-3207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-957-4165
Provider Business Mailing Address Fax Number:
770-957-2003

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
130 JOHN FRANK WARD BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCDONOUGH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30253-3207
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-957-4165
Provider Business Practice Location Address Fax Number:
770-957-2003
Provider Enumeration Date:
12/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
HOOVER
Authorized Official First Name:
JASON
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER DOCTOR
Authorized Official Telephone Number:
770-957-4165

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: DA7894 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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