Healthcare Provider Details

I. General information

NPI: 1578938395
Provider Name (Legal Business Name): HANOWELL SPINE CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 08/15/2025
Certification Date: 08/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4142 MILL ST NE
COVINGTON GA
30014-2540
US

IV. Provider business mailing address

4142 MILL ST NE
COVINGTON GA
30014-2540
US

V. Phone/Fax

Practice location:
  • Phone: 770-225-0098
  • Fax: 770-787-2304
Mailing address:
  • Phone: 770-787-3550
  • Fax: 770-787-2304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JADE WOODLEY
Title or Position: OFFICE MANAGER
Credential:
Phone: 770-787-3550