Provider Demographics
NPI:1043499700
Name:THE CHATTANOOGA SPINE AND WELLNESS INSTITUTE, INC
Entity Type:Organization
Organization Name:THE CHATTANOOGA SPINE AND WELLNESS INSTITUTE, INC
Other - Org Name:SOUTHEAST CENTER FOR BONE AND JOINT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:423-296-2604
Mailing Address - Street 1:1334 MACKEY BRANCH DRIVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-3471
Mailing Address - Country:US
Mailing Address - Phone:423-296-2604
Mailing Address - Fax:423-296-2607
Practice Address - Street 1:1334 MACKEY BRANCH DRIVE
Practice Address - Street 2:SUITE 103
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-3471
Practice Address - Country:US
Practice Address - Phone:423-296-2604
Practice Address - Fax:423-296-2607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-30
Last Update Date:2021-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2465111N00000X
TN40410208D00000X
TN52292208D00000X
TN17939363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU78769Medicare UPIN
GA35ZCGWPMedicare PIN