Provider Demographics
NPI:1285924159
Name:AVENTINE INJURY CENTER
Entity type:Organization
Organization Name:AVENTINE INJURY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:GIOVONNI
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-913-3972
Mailing Address - Street 1:1078 CLEVELAND AVE
Mailing Address - Street 2:1078 CLEVELAND AVENUE
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30344-6741
Mailing Address - Country:US
Mailing Address - Phone:678-824-4768
Mailing Address - Fax:
Practice Address - Street 1:1078 CLEVELAND AVE
Practice Address - Street 2:1078 CLEVELAND AVENUE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30344-6741
Practice Address - Country:US
Practice Address - Phone:678-824-4768
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVENTINE CHIROPRACTIC AND WELLNESS CLINIC, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-04-13
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA008794111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty