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General NPI Number Information
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NPI Number | 1336316629
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Entity Type | Organization
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Legal Business Name | COLUMBUS SPINE AND PERFORMANCE CENTER, LLC
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Dates
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Enumeration Date | 05/15/2008
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Last Update Date | 05/15/2008
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Provider Practice Location Address
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Address Line | 1714 MANCHESTER EXPY
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City | COLUMBUS
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State | GA
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Zip | 31904-6748
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Country | US
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Telephone | 706-596-0909
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Fax | 706-596-0919
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Provider Business Mailing Address
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Address Line | 1714 MANCHESTER EXPY
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City | COLUMBUS
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State | GA
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Zip | 31904-6748
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Country | US
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Telephone | 706-596-0909
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Fax | 706-596-0919
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Authorized Official
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Title or Position | SHAREHOLDER
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Name | DR. GORDON LESLIE STEPHENSON JR.
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Credential | D.C.
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Telephone | 706-596-0909
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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 | GA005828
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License Number State | GA
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