MEDICARE: HANOWELL SPINE CLINIC 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	208VP0014X	Interventional Pain Medicine Physician
2	208VP0000X	Pain Medicine Physician

General Provider Information

NPI Number	:	1578938395
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HANOWELL SPINE CLINIC LLC

Provider Business Mailing Address
First Line	:	4142 MILL ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-2540
Country	:	US
Telephone Number	:	770-787-3550
Fax Number	:	770-787-2304

Provider Business Practice Location Address
First Line	:	4142 MILL ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-2540
Country	:	US
Telephone Number	:	770-225-0098
Fax Number	:	770-787-2304

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	JADE WOODLEY
Credential	:
Telephone Number	:	770-787-3550

Provider Enumeration Date	:	12/04/2015
Last Update Date	:	08/15/2025

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Directions to “HANOWELL SPINE CLINIC LLC ” Practice Location

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