MEDICARE: SOUTHWORTH ACTIVE SPINE AND REHAB

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	111N00000X	Chiropractor	DC4208	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831550961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHWORTH ACTIVE SPINE AND REHAB

Provider Business Mailing Address
First Line	:	8076 E BROAD ST
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-8024
Country	:	US
Telephone Number	:	614-986-9103
Fax Number	:	614-986-9619

Provider Business Practice Location Address
First Line	:	8076 EAST BROAD STREET
Second Line	:
City	:	REYNOLDSBURG
State	:	OH
Zip	:	43068-8024
Country	:	US
Telephone Number	:	614-986-9103
Fax Number	:	614-986-9619

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. THEODORA NOEL DAWES-BAILEY
Credential	:
Telephone Number	:	614-404-9703

Provider Enumeration Date	:	03/17/2016
Last Update Date	:	03/17/2016

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Directions to “SOUTHWORTH ACTIVE SPINE AND REHAB ” Practice Location

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