=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548476716
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COVINGTON SPINE CENTER, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 305 S THREE NOTCH ST
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36420-4427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-428-2225
-----------------------------------------------------
Fax | 334-428-2222
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 42
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36420-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-428-2225
-----------------------------------------------------
Fax | 334-428-2222
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | NIKKI COBB
-----------------------------------------------------
Credential | BBA
-----------------------------------------------------
Telephone | 334-428-2225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | AL 1919
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------