Provider Demographics
NPI:1851715767
Name:PETTYGROVE, JOHN JEREMY (DC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JEREMY
Last Name:PETTYGROVE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 WATSON BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31093-9526
Mailing Address - Country:US
Mailing Address - Phone:770-982-4886
Mailing Address - Fax:770-979-2275
Practice Address - Street 1:3035 WATSON BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-9526
Practice Address - Country:US
Practice Address - Phone:770-982-4886
Practice Address - Fax:770-979-2275
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-12
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009223111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor