MEDICARE: DYNAMIC SPINE CENTER

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	111NS0005X	Sports Physician Chiropractor	CHIR009256	GA
2	111NR0400X	Rehabilitation Chiropractor	CHIR009256	GA

General Provider Information

NPI Number	:	1699174896
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC SPINE CENTER

Provider Business Mailing Address
First Line	:	2836 HIGHWAY 54
Second Line	:	SUITE 2836
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1026
Country	:	US
Telephone Number	:	770-742-9801
Fax Number	:

Provider Business Practice Location Address
First Line	:	2836 HIGHWAY 54
Second Line	:	SUITE 2836
City	:	PEACHTREE CITY
State	:	GA
Zip	:	30269-1026
Country	:	US
Telephone Number	:	770-742-9801
Fax Number	:

Authorized Official
Title or Position	:	CO OWNER/ CLINICAL DIRECTOR
Name	:	DR. DUSTIN R WALTON
Credential	:	D.C.
Telephone Number	:	770-742-9801

Provider Enumeration Date	:	08/14/2014
Last Update Date	:	08/14/2014

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Directions to “DYNAMIC SPINE CENTER ” Practice Location

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