=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598868416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1011 WOODRIDGE LANE BLDG. 301
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-6077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-310-1121
-----------------------------------------------------
Fax | 706-310-1165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1011 WOODRIDGE LANE BLDG. 301
-----------------------------------------------------
City | WATKINSVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30677-6077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-310-1121
-----------------------------------------------------
Fax | 706-310-1165
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/CEO
-----------------------------------------------------
Name | DR. BRYAN KEITH HOOPER
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 706-310-1121
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 6752
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------