Provider Demographics
NPI:1528297520
Name:WELLSPRING CHIROPRACTIC PC
Entity type:Organization
Organization Name:WELLSPRING CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELAIA
Authorized Official - Middle Name:TAJUAN
Authorized Official - Last Name:PAYTON
Authorized Official - Suffix:
Authorized Official - Credentials:BS, DC
Authorized Official - Phone:404-826-1425
Mailing Address - Street 1:235 E PONCE DE LEON AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-3412
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:235 E PONCE DE LEON AVE STE 109
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-3412
Practice Address - Country:US
Practice Address - Phone:404-826-1425
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-11
Last Update Date:2009-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007660111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty