MEDICARE: PRIDGEN CHIROPRACTIC & WELLNESS CENTER PC

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	111NR0400X	Rehabilitation Chiropractor	1133	GA

General Provider Information

NPI Number	:	1124220512
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIDGEN CHIROPRACTIC & WELLNESS CENTER PC

Provider Business Mailing Address
First Line	:	3338 COUNTRY CLUB RD
Second Line	:	BLDG F STE3
City	:	VALDOSTA
State	:	GA
Zip	:	31605-1044
Country	:	US
Telephone Number	:	229-244-5314
Fax Number	:

Provider Business Practice Location Address
First Line	:	3338 COUNTRY CLUB RD
Second Line	:	BULDG F STE3
City	:	VALDOSTA
State	:	GA
Zip	:	31605-1044
Country	:	US
Telephone Number	:	229-244-5314
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. LEO DAVID PRIDGEN JR.
Credential	:	DC
Telephone Number	:	229-244-5314

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	08/22/2020

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