MEDICARE: BODY WORKS CHIROPRACTIC AND WELLNESS CENTER, LLC

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	CHR006755	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CHR006755	OTHER	GA	DC LICENSE

General Provider Information

NPI Number	:	1235444647
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BODY WORKS CHIROPRACTIC AND WELLNESS CENTER, LLC

Provider Business Mailing Address
First Line	:	68 GLOBAL DR
Second Line	:	SUITE 100
City	:	GREENVILLE
State	:	SC
Zip	:	29607-4628
Country	:	US
Telephone Number	:	864-644-2700
Fax Number	:	864-644-2709

Provider Business Practice Location Address
First Line	:	2330 WINDY HILL RD SE
Second Line	:	STE. 200
City	:	MARIETTA
State	:	GA
Zip	:	30067-8602
Country	:	US
Telephone Number	:	770-988-0988
Fax Number	:	770-988-8989

Authorized Official
Title or Position	:	OWNER
Name	:	KEVIN D FLYTHE
Credential	:	DC
Telephone Number	:	770-988-0988

Provider Enumeration Date	:	08/10/2010
Last Update Date	:	10/28/2010

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