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General NPI Number Information
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NPI Number | 1598173155
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Entity Type | Organization
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Legal Business Name | DIVINE SPINE CHIROPRACTIC
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Dates
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Enumeration Date | 07/28/2014
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Last Update Date | 09/30/2014
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Provider Practice Location Address
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Address Line | 4205 CROSSINGS BLVD
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City | PRINCE GEORGE
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State | VA
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Zip | 23875
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Country | US
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Telephone | 804-668-5918
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Fax |
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Provider Business Mailing Address
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Address Line | 4205 CROSSINGS BLVD
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City | PRINCE GEORGE
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State | VA
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Zip | 23875
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Country | US
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Telephone | 804-668-5918
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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. BRAHEEM Z TOLBERT
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Credential | DC
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Telephone | 804-668-5918
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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 | 0104-557187
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License Number State | VA
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