=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891220414
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RIDGE CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2017
-----------------------------------------------------
Last Update Date | 04/21/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 39 LANCE ST UNIT 6
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-8024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-317-7583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 39 LANCE ST UNIT 6
-----------------------------------------------------
City | BLUE RIDGE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30513-8024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-317-7583
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. RICHARD GROSTIC
-----------------------------------------------------
Credential | D.C.
-----------------------------------------------------
Telephone | 770-317-7583
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | CHIRO07653
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------