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General NPI Number Information
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NPI Number | 1578915401
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Entity Type | Organization
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Legal Business Name | BIOSPINE HEALTH AND WELNESS, LLC
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Dates
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Enumeration Date | 07/03/2016
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Last Update Date | 07/03/2016
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Provider Practice Location Address
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Address Line | 542 BEN GAUSE RD
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City | COWARD
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State | SC
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Zip | 29530-5127
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Country | US
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Telephone | 843-940-0687
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Fax |
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Provider Business Mailing Address
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Address Line | 542 BEN GAUSE RD
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City | COWARD
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State | SC
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Zip | 29530-5127
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Country | US
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Telephone | 843-940-0687
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHUCKY SENTELL JORDAN
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Credential | DC
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Telephone | 843-940-0687
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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 | SC 4099
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License Number State | SC
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