MEDICARE: RENFRED R. HALVERSON DC., P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	CHIRO01742	GA
2	111N00000X	Chiropractor	GA1742	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1043324296	OTHER	GA	GROUP NPI NUMBER
2	GRP7792	OTHER	GA	PTAN #

General Provider Information

NPI Number	:	1043324296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENFRED R. HALVERSON DC., P.C.

Provider Business Mailing Address
First Line	:	1510 NEWCASTLE ST STE 200
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-6825
Country	:	US
Telephone Number	:	912-262-9735
Fax Number	:	912-262-9634

Provider Business Practice Location Address
First Line	:	1510 NEWCASTLE ST STE 200
Second Line	:
City	:	BRUNSWICK
State	:	GA
Zip	:	31520-6825
Country	:	US
Telephone Number	:	912-262-9735
Fax Number	:	912-262-9634

Authorized Official
Title or Position	:	OWNER/ADMINISTRATOR
Name	:	REN R HALVERSON
Credential	:	DC
Telephone Number	:	912-262-9735

Provider Enumeration Date	:	08/17/2006
Last Update Date	:	05/05/2023

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