Provider Demographics
NPI:1538679394
Name:SOUTHERN CHIROPRACTIC OF DOUGLAS, INC.
Entity type:Organization
Organization Name:SOUTHERN CHIROPRACTIC OF DOUGLAS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSHUA
Authorized Official - Middle Name:BRETT
Authorized Official - Last Name:MIZELL
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:912-389-0042
Mailing Address - Street 1:506 ASHLEY ST W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-2308
Mailing Address - Country:US
Mailing Address - Phone:912-389-0042
Mailing Address - Fax:
Practice Address - Street 1:506 ASHLEY ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2308
Practice Address - Country:US
Practice Address - Phone:912-389-0042
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GACHIR008807OtherPROFESSIONAL LICENSE