Provider Demographics
NPI:1649573130
Name:AZALEA CITY CHIROPRACTIC
Entity Type:Organization
Organization Name:AZALEA CITY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:MINK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:2292-419-3000
Mailing Address - Street 1:2231 BEMISS RD STE B
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-4812
Mailing Address - Country:US
Mailing Address - Phone:229-241-9300
Mailing Address - Fax:
Practice Address - Street 1:2231 BEMISS RD STE B
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-4812
Practice Address - Country:US
Practice Address - Phone:229-241-9300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-06
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008116111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty