=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710354329
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HUNTSVILLE SPINE AND REHAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2015
-----------------------------------------------------
Last Update Date | 08/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 303 WILLIAMS AVE SW SUITE 117
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-6012
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-519-3550
-----------------------------------------------------
Fax | 256-513-4890
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 303 WILLIAMS AVENUE SW SUITE 114
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35801-6001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-519-3550
-----------------------------------------------------
Fax | 256-513-4890
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | GREGORY MILLAR
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 256-519-3550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------