Provider Demographics
NPI:1699174896
Name:DYNAMIC SPINE CENTER
Entity type:Organization
Organization Name:DYNAMIC SPINE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO OWNER/ CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DUSTIN
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-742-9801
Mailing Address - Street 1:2836 HIGHWAY 54
Mailing Address - Street 2:SUITE 2836
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-1026
Mailing Address - Country:US
Mailing Address - Phone:770-742-9801
Mailing Address - Fax:
Practice Address - Street 1:2836 HIGHWAY 54
Practice Address - Street 2:SUITE 2836
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-1026
Practice Address - Country:US
Practice Address - Phone:770-742-9801
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009256111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty