Provider Demographics
NPI:1336316629
Name:COLUMBUS SPINE AND PERFORMANCE CENTER, LLC
Entity Type:Organization
Organization Name:COLUMBUS SPINE AND PERFORMANCE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SHAREHOLDER
Authorized Official - Prefix:DR
Authorized Official - First Name:GORDON
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:706-596-0909
Mailing Address - Street 1:1714 MANCHESTER EXPY
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-6748
Mailing Address - Country:US
Mailing Address - Phone:706-596-0909
Mailing Address - Fax:706-596-0919
Practice Address - Street 1:1714 MANCHESTER EXPY
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904-6748
Practice Address - Country:US
Practice Address - Phone:706-596-0909
Practice Address - Fax:706-596-0919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA005828111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GRP4198OtherMEDICAGE GROUP NUMBER