Provider Demographics
NPI:1922145812
Name:BOUTWELL CHIROPRACTIC GROUP PC
Entity Type:Organization
Organization Name:BOUTWELL CHIROPRACTIC GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRELL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BOUTWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-860-8717
Mailing Address - Street 1:3665 WHEELER RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6603
Mailing Address - Country:US
Mailing Address - Phone:706-860-8717
Mailing Address - Fax:706-860-1341
Practice Address - Street 1:3665 WHEELER RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6603
Practice Address - Country:US
Practice Address - Phone:706-860-8717
Practice Address - Fax:706-860-1341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3349Medicare ID - Type Unspecified