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General NPI Number Information
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NPI Number | 1467796581
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Entity Type | Organization
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Legal Business Name | SOUTHEAST CHIROPRACTIC CLINIC LLC
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Dates
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Enumeration Date | 11/15/2012
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Last Update Date | 11/15/2012
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Provider Practice Location Address
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Address Line | 308 JACKSON ST
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City | VIDALIA
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State | GA
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Zip | 30474-4708
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Country | US
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Telephone | 912-585-7124
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Fax |
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Provider Business Mailing Address
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Address Line | 107 RESERVE CIR
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City | SAINT MARYS
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State | GA
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Zip | 31558-4278
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Country | US
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Telephone | 912-585-7124
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | HEIDI ZUBECK
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Credential |
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Telephone | 912-585-7124
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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 | CHIR008450
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License Number State | GA
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