=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972113215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER CHIROPRACTIC CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2020
-----------------------------------------------------
Last Update Date | 08/02/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5031 FORD PKWY STE 112
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35022-5286
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-747-3065
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 40
-----------------------------------------------------
City | BESSEMER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35021-0040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. ROSHUN GLOVER SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 601-260-2487
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------