Basic Information
| Provider Information | |||||||||
| NPI: | 1588079818 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SPORTS DOC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2505 NEWPOINT PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702713188 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2505 NEWPOINT PKWY | ||||||||
| Address2: | STE 200 | ||||||||
| City: | LAWRENCEVILLE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300436003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702713188 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2014 | ||||||||
| LastUpdateDate: | 06/25/2014 | ||||||||
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| AuthorizedOfficialLastName: | HIGGINS | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7702713188 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 3034 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.