Provider Demographics
NPI:1821177080
Name:ATLANTIC SPINE,LLC
Entity Type:Organization
Organization Name:ATLANTIC SPINE,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:P
Authorized Official - Last Name:GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:843-497-5197
Mailing Address - Street 1:1105 48TH AVE N STE 106
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5419
Mailing Address - Country:US
Mailing Address - Phone:843-497-5197
Mailing Address - Fax:
Practice Address - Street 1:1105 48TH AVE N STE 106
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5419
Practice Address - Country:US
Practice Address - Phone:843-497-5197
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2736Medicaid