Provider Demographics
NPI:1285983270
Name:INNER SANCTUARY CHIROPRACTIC LLC
Entity type:Organization
Organization Name:INNER SANCTUARY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NIMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAHALLATI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-993-1140
Mailing Address - Street 1:165 DEKALB INDUSTRIAL WAY
Mailing Address - Street 2:SUITE B5
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2230
Mailing Address - Country:US
Mailing Address - Phone:404-993-1140
Mailing Address - Fax:
Practice Address - Street 1:165 DEKALB INDUSTRIAL WAY
Practice Address - Street 2:SUITE B5
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2230
Practice Address - Country:US
Practice Address - Phone:404-993-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-05
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008617111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty