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General NPI Number Information
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NPI Number | 1649684499
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Entity Type | Organization
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Legal Business Name | BACK 2 LIFE WELLNESS STUDIOS OF CARTERSVILLE, LLC
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Dates
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Enumeration Date | 06/19/2014
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Last Update Date | 06/19/2014
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Provider Practice Location Address
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Address Line | 807 WEST AVE SUITE G
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City | CARTERSVILLE
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State | GA
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Zip | 30120-8230
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Country | US
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Telephone | 678-985-0444
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Fax |
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Provider Business Mailing Address
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Address Line | 807 WEST AVE SUITE G
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City | CARTERSVILLE
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State | GA
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Zip | 30120-8230
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Country | US
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Telephone | 678-985-0444
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. ANDRE CHRISTOPHER HINES
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Credential | D.C
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Telephone | 678-985-0444
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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 | CHIR009196
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License Number State | GA
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