Provider Demographics
NPI:1598173155
Name:DIVINE SPINE CHIROPRACTIC
Entity Type:Organization
Organization Name:DIVINE SPINE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAHEEM
Authorized Official - Middle Name:Z
Authorized Official - Last Name:TOLBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:804-668-5918
Mailing Address - Street 1:4205 CROSSINGS BLVD
Mailing Address - Street 2:
Mailing Address - City:PRINCE GEORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23875
Mailing Address - Country:US
Mailing Address - Phone:804-668-5918
Mailing Address - Fax:
Practice Address - Street 1:4205 CROSSINGS BLVD
Practice Address - Street 2:
Practice Address - City:PRINCE GEORGE
Practice Address - State:VA
Practice Address - Zip Code:23875
Practice Address - Country:US
Practice Address - Phone:804-668-5918
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-557187111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty