Provider Demographics
NPI:1184048092
Name:RENOVATION CHIROPRACTIC, INC.
Entity type:Organization
Organization Name:RENOVATION CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:JEREMY
Authorized Official - Last Name:PETTYGROVE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:478-334-7958
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-12
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO009223111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty