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General NPI Number Information
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NPI Number | 1346571338
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Entity Type | Organization
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Legal Business Name | BACK IN MOTION CLINIC OF CHIROPRACTIC
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Dates
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Enumeration Date | 01/15/2010
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Last Update Date | 01/15/2010
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Provider Practice Location Address
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Address Line | 703 FAIRVIEW ST
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City | FOUNTAIN INN
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State | SC
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Zip | 29644-1541
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Country | US
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Telephone | 864-601-9012
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 1511
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City | FOUNTAIN INN
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State | SC
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Zip | 29644-1058
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Country | US
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Telephone | 864-601-9012
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHARLES GEORGE GOLDIZEN II
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Credential | D.C.
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Telephone | 864-601-9012
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number | 3498
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License Number State | SC
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