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General NPI Number Information
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NPI Number | 1184048092
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Entity Type | Organization
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Legal Business Name | RENOVATION CHIROPRACTIC, INC.
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Dates
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Enumeration Date | 02/12/2014
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Last Update Date | 05/05/2014
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Provider Practice Location Address
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Address Line | 3035 WATSON BLVD SUITE 5
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City | WARNER ROBINS
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State | GA
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Zip | 31093-9526
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Country | US
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Telephone | 770-982-4886
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Fax | 770-979-2275
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Provider Business Mailing Address
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Address Line | 3035 WATSON BLVD SUITE 5
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City | WARNER ROBINS
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State | GA
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Zip | 31093-9526
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Country | US
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Telephone | 770-982-4886
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Fax | 770-979-2275
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Authorized Official
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Title or Position | PROVIDER/PRESIDENT
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Name | JOHN JEREMY PETTYGROVE
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Credential | DC
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Telephone | 478-334-7958
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | CHIRO009223
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License Number State | GA
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