=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538583752
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CANTON WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2014
-----------------------------------------------------
Last Update Date | 01/15/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1558 MARIETTA HWY SUITE 100
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30114-3616
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-310-2086
-----------------------------------------------------
Fax | 770-992-3676
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1057
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30169-1057
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-310-2086
-----------------------------------------------------
Fax | 770-992-3676
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | JOHN C MEINERS
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 770-720-4090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIR005446
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------