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General NPI Number Information
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NPI Number | 1679809644
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Entity Type | Organization
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Legal Business Name | EASTERN SHORE CHIROPRACTIC & SPORTS CLINIC, INC
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Dates
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Enumeration Date | 10/27/2009
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Last Update Date | 10/27/2009
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Provider Practice Location Address
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Address Line | 151 FLY CREEK AVENUE SUITE 411
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City | FAIRHOPE
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State | AL
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Zip | 36532-3843
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Country | US
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Telephone | 225-274-5507
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Fax |
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Provider Business Mailing Address
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Address Line | 151 FLY CREEK AVENUE SUITE 411
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City | FAIRHOPE
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State | AL
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Zip | 36532-3843
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Country | US
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Telephone | 225-274-5507
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/OWNER
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Name | DR. JUSTIN FISHER SOUTHALL
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Credential | D.C.
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Telephone | 225-274-5507
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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 | 2292
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License Number State | AL
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