Provider Demographics
NPI:1194791020
Name:HALVERSON, REN R (DC PC)
Entity type:Individual
Prefix:DR
First Name:REN
Middle Name:R
Last Name:HALVERSON
Suffix:
Gender:M
Credentials:DC PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3366 CYPRESS MILL RD.
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-4712
Mailing Address - Country:US
Mailing Address - Phone:912-262-9735
Mailing Address - Fax:912-262-9634
Practice Address - Street 1:3366 CYPRESS MILL RD.
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-4712
Practice Address - Country:US
Practice Address - Phone:912-262-9735
Practice Address - Fax:912-262-9634
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001742111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAT-97622Medicare UPIN
GAT97622Medicare UPIN