Provider Demographics
NPI:1851444103
Name:COVENANT CHIROPRACTIC CENTER PC
Entity Type:Organization
Organization Name:COVENANT CHIROPRACTIC CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOOD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:478-934-8855
Mailing Address - Street 1:169 W DYKES STREET
Mailing Address - Street 2:
Mailing Address - City:COCHRAN
Mailing Address - State:GA
Mailing Address - Zip Code:31014
Mailing Address - Country:US
Mailing Address - Phone:478-934-8855
Mailing Address - Fax:478-934-8855
Practice Address - Street 1:169 W DYKES STREET
Practice Address - Street 2:
Practice Address - City:COCHRAN
Practice Address - State:GA
Practice Address - Zip Code:31014
Practice Address - Country:US
Practice Address - Phone:478-934-8855
Practice Address - Fax:478-934-8855
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
005109111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
35ZCCLVMedicare ID - Type Unspecified