Provider Demographics
NPI:1780063800
Name:MAGNA CHIROPRACTIC SPINE CENTER OF BOWLING GREEN
Entity type:Organization
Organization Name:MAGNA CHIROPRACTIC SPINE CENTER OF BOWLING GREEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HAWLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-746-9400
Mailing Address - Street 1:830 FAIRVIEW AVE STE A-3
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101
Mailing Address - Country:US
Mailing Address - Phone:270-746-9400
Mailing Address - Fax:270-746-0240
Practice Address - Street 1:830 FAIRVIEW AVE STE A-3
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101
Practice Address - Country:US
Practice Address - Phone:270-746-9400
Practice Address - Fax:270-746-0240
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-21
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4859Medicaid