Provider Demographics
NPI:1023201217
Name:PINE MOUNTAIN CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:PINE MOUNTAIN CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:W
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MANAGING MEMBER
Authorized Official - Phone:706-663-8801
Mailing Address - Street 1:624 N MAIN AVE
Mailing Address - Street 2:P.O. BOX 1690
Mailing Address - City:PINE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:31822-2403
Mailing Address - Country:US
Mailing Address - Phone:706-663-8801
Mailing Address - Fax:
Practice Address - Street 1:624 N MAIN AVE
Practice Address - Street 2:
Practice Address - City:PINE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:31822-2403
Practice Address - Country:US
Practice Address - Phone:706-663-8801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2301000RN261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service