Provider Demographics
NPI:1104105733
Name:DR. JAY ROSA, CHIROPRACTOR, LLC
Entity type:Organization
Organization Name:DR. JAY ROSA, CHIROPRACTOR, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EFMAM
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:ROSA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-837-5609
Mailing Address - Street 1:76 HIGHLAND PAVILION CT
Mailing Address - Street 2:
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3169
Mailing Address - Country:US
Mailing Address - Phone:770-439-6997
Mailing Address - Fax:636-707-9772
Practice Address - Street 1:76 HIGHLAND PAVILION CT
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3169
Practice Address - Country:US
Practice Address - Phone:770-439-6997
Practice Address - Fax:636-707-9772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-14
Last Update Date:2012-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008582261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center