Provider Demographics
NPI:1386362978
Name:100 CHIRO BOURNE LLC
Entity type:Organization
Organization Name:100 CHIRO BOURNE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RAVEN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:HOUSE-BOURNE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:504-333-9084
Mailing Address - Street 1:403 DARTER DR NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-5083
Mailing Address - Country:US
Mailing Address - Phone:504-333-9084
Mailing Address - Fax:
Practice Address - Street 1:3512 HIGHWAY 155 N STE A2
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-5506
Practice Address - Country:US
Practice Address - Phone:504-333-9084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-18
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty