1205351863 NPI number — CHIROSOUTH SPINE AND SPORT LLC

Table of content: (NPI 1205351863)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205351863 NPI number — CHIROSOUTH SPINE AND SPORT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIROSOUTH SPINE AND SPORT LLC
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:
1205351863
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/04/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 FLY CREEK AVE STE 411
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRHOPE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36532-8308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-990-8383
Provider Business Mailing Address Fax Number:
850-990-8399

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
277 MCGREGOR AVE S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOBILE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36608-2340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-990-8383
Provider Business Practice Location Address Fax Number:
251-990-8399
Provider Enumeration Date:
08/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
SOUTHALL
Authorized Official First Name:
JUSTIN
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
850-990-8383

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2292 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com