Healthcare Provider Details

I. General information

NPI: 1336316629
Provider Name (Legal Business Name): COLUMBUS SPINE AND PERFORMANCE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 05/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 MANCHESTER EXPY
COLUMBUS GA
31904-6748
US

IV. Provider business mailing address

1714 MANCHESTER EXPY
COLUMBUS GA
31904-6748
US

V. Phone/Fax

Practice location:
  • Phone: 706-596-0909
  • Fax: 706-596-0919
Mailing address:
  • Phone: 706-596-0909
  • Fax: 706-596-0919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberGA005828
License Number StateGA

VIII. Authorized Official

Name: DR. GORDON LESLIE STEPHENSON JR.
Title or Position: SHAREHOLDER
Credential: D.C.
Phone: 706-596-0909