Provider Demographics
NPI:1841798279
Name:PERFORMANCE SPORT AND SPINE
Entity type:Organization
Organization Name:PERFORMANCE SPORT AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHRIOPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-721-4406
Mailing Address - Street 1:1575 OLD ALABAMA RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-2133
Mailing Address - Country:US
Mailing Address - Phone:404-721-4406
Mailing Address - Fax:404-601-5101
Practice Address - Street 1:1575 OLD ALABAMA RD STE 105
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-2133
Practice Address - Country:US
Practice Address - Phone:404-721-4406
Practice Address - Fax:404-601-5101
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005801111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty