Provider Demographics
NPI:1831550961
Name:SOUTHWORTH ACTIVE SPINE AND REHAB
Entity type:Organization
Organization Name:SOUTHWORTH ACTIVE SPINE AND REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:THEODORA
Authorized Official - Middle Name:NOEL
Authorized Official - Last Name:DAWES-BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-404-9703
Mailing Address - Street 1:8076 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-8024
Mailing Address - Country:US
Mailing Address - Phone:614-986-9103
Mailing Address - Fax:614-986-9619
Practice Address - Street 1:8076 EAST BROAD STREET
Practice Address - Street 2:
Practice Address - City:REYNOLDSBURG
Practice Address - State:OH
Practice Address - Zip Code:43068-8024
Practice Address - Country:US
Practice Address - Phone:614-986-9103
Practice Address - Fax:614-986-9619
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHDC4208111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1538421672Medicaid
OH1538421672Medicare NSC