Provider Demographics
NPI:1962448852
Name:ISLAND CHIROPRACTIC & WELLNESS CTR
Entity Type:Organization
Organization Name:ISLAND CHIROPRACTIC & WELLNESS CTR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DOCTOR OF CHIROPRACTIC MEDICI
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWARD
Authorized Official - Middle Name:A
Authorized Official - Last Name:BERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:912-634-2245
Mailing Address - Street 1:132 RETREAT PLAZA
Mailing Address - Street 2:STE B
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522
Mailing Address - Country:US
Mailing Address - Phone:912-634-2245
Mailing Address - Fax:912-634-8780
Practice Address - Street 1:132 RETREAT PLAZA
Practice Address - Street 2:STE B
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522
Practice Address - Country:US
Practice Address - Phone:912-634-2245
Practice Address - Fax:912-634-8780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5872111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U70774Medicare UPIN
GA35ZCGSTMedicare ID - Type Unspecified