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General NPI Number Information
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NPI Number | 1699174896
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Entity Type | Organization
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Legal Business Name | DYNAMIC SPINE CENTER
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Dates
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Enumeration Date | 08/14/2014
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Last Update Date | 08/14/2014
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Provider Practice Location Address
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Address Line | 2836 HIGHWAY 54 SUITE 2836
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-1026
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Country | US
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Telephone | 770-742-9801
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Fax |
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Provider Business Mailing Address
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Address Line | 2836 HIGHWAY 54 SUITE 2836
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-1026
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Country | US
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Telephone | 770-742-9801
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Fax |
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Authorized Official
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Title or Position | CO OWNER/ CLINICAL DIRECTOR
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Name | DR. DUSTIN R WALTON
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Credential | D.C.
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Telephone | 770-742-9801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111NS0005X
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Taxonomy Name | Sports Physician Chiropractor
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License Number | CHIR009256
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 111NR0400X
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Taxonomy Name | Rehabilitation Chiropractor
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License Number | CHIR009256
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License Number State | GA
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