Provider Demographics
NPI:1316093115
Name:CACKOWSKI, SUSAN (DC)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:
Last Name:CACKOWSKI
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6861 PARKWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:678-858-5932
Mailing Address - Fax:678-858-5932
Practice Address - Street 1:111 LOVVORN AVE
Practice Address - Street 2:
Practice Address - City:BOWDON
Practice Address - State:GA
Practice Address - Zip Code:30108
Practice Address - Country:US
Practice Address - Phone:770-258-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0643111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor