Provider Demographics
NPI:1760732523
Name:COLQUITT CHIROPRACTIC, LP
Entity Type:Organization
Organization Name:COLQUITT CHIROPRACTIC, LP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WINSTON
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:BALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:229-985-5000
Mailing Address - Street 1:PO BOX 2215
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2215
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2939 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768-6903
Practice Address - Country:US
Practice Address - Phone:229-985-5000
Practice Address - Fax:229-985-1107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-19
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR01580111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00519769AMedicaid
GA00519769AMedicaid