Provider Demographics
NPI:1275357642
Name:TAVERA, BRIAN (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:TAVERA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 SUWANEE DAM RD STE 200
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-5648
Mailing Address - Country:US
Mailing Address - Phone:678-714-3053
Mailing Address - Fax:
Practice Address - Street 1:5910 SUWANEE DAM RD STE 200
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-5648
Practice Address - Country:US
Practice Address - Phone:678-714-3053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR011274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty