Provider Demographics
NPI:1356549935
Name:SPINE DYNAMICS PC
Entity type:Organization
Organization Name:SPINE DYNAMICS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:STUART
Authorized Official - Last Name:COPES
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:706-543-2111
Mailing Address - Street 1:788 PRINCE AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-5912
Mailing Address - Country:US
Mailing Address - Phone:706-543-2111
Mailing Address - Fax:706-543-2190
Practice Address - Street 1:788 PRINCE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-5912
Practice Address - Country:US
Practice Address - Phone:706-543-2111
Practice Address - Fax:706-543-2190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT004796225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7220Medicare ID - Type Unspecified
GAQ47476Medicare UPIN