MEDICARE: PINE MOUNTAIN CHIROPRACTIC CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center	2301000RN	GA

General Provider Information

NPI Number	:	1023201217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PINE MOUNTAIN CHIROPRACTIC CENTER, LLC

Provider Business Mailing Address
First Line	:	624 N MAIN AVE
Second Line	:	P.O. BOX 1690
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-2403
Country	:	US
Telephone Number	:	706-663-8801
Fax Number	:

Provider Business Practice Location Address
First Line	:	624 N MAIN AVE
Second Line	:
City	:	PINE MOUNTAIN
State	:	GA
Zip	:	31822-2403
Country	:	US
Telephone Number	:	706-663-8801
Fax Number	:

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	KIM W. RUSSELL
Credential	:	MANAGING MEMBER
Telephone Number	:	706-663-8801

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	08/22/2007

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