Provider Demographics
NPI:1194357046
Name:PROSPINE WELLNESS & INJURY CARE PC
Entity Type:Organization
Organization Name:PROSPINE WELLNESS & INJURY CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:602-430-6994
Mailing Address - Street 1:3430 HARRIS FARMS WAY
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30106-8017
Mailing Address - Country:US
Mailing Address - Phone:602-430-6994
Mailing Address - Fax:
Practice Address - Street 1:4200 WADE GREEN RD NW STE 204
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1808
Practice Address - Country:US
Practice Address - Phone:602-430-6994
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-09
Last Update Date:2020-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty