Provider Demographics
NPI:1205351863
Name:CHIROSOUTH SPINE AND SPORT LLC
Entity type:Organization
Organization Name:CHIROSOUTH SPINE AND SPORT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:SOUTHALL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:850-990-8383
Mailing Address - Street 1:151 FLY CREEK AVE STE 411
Mailing Address - Street 2:
Mailing Address - City:FAIRHOPE
Mailing Address - State:AL
Mailing Address - Zip Code:36532-8308
Mailing Address - Country:US
Mailing Address - Phone:850-990-8383
Mailing Address - Fax:850-990-8399
Practice Address - Street 1:277 MCGREGOR AVE S
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36608-2340
Practice Address - Country:US
Practice Address - Phone:251-990-8383
Practice Address - Fax:251-990-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-04
Last Update Date:2017-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2292111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty