=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538510060
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B2L CHIRO, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2016
-----------------------------------------------------
Last Update Date | 06/27/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 WEST AVE STE G
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120-8230
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-686-7907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 807 W. AVE SUITE G
-----------------------------------------------------
City | CARTERSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-686-7907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | DR. ANDRE CHRISTOPHER HINES
-----------------------------------------------------
Credential | D.C
-----------------------------------------------------
Telephone | 562-686-7907
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIRO09196
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------