=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851613996
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SPINE AND JOINT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/16/2010
-----------------------------------------------------
Last Update Date | 10/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 209 MUSGROVE ST
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-547-1607
-----------------------------------------------------
Fax | 864-547-1606
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 209
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29325-0209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-547-2250
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | RYAN V WILLIAMS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 864-547-2250
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3524
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------