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General NPI Number Information
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NPI Number | 1659629723
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Entity Type | Organization
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Legal Business Name | DYNAMIC SPINE AND SPORTS THERAPY
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Dates
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Enumeration Date | 08/21/2012
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Last Update Date | 08/21/2012
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Provider Practice Location Address
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Address Line | 3400 BLUE SPRINGS RD NW SUITE 100
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City | KENNESAW
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State | GA
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Zip | 30144-1079
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Country | US
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Telephone | 678-674-5430
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Fax |
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Provider Business Mailing Address
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Address Line | 3400 BLUE SPRINGS RD NW SUITE 100
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City | KENNESAW
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State | GA
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Zip | 30144-1079
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Country | US
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Telephone | 678-674-5430
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Fax |
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Authorized Official
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Title or Position | MEMBER
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Name | DR. JERED MICHAEL HULL
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Credential | CHIROPRACTIC
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Telephone | 678-674-5430
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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 | 055355792
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License Number State | GA
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