Provider Demographics
NPI:1386714319
Name:HATTAWAY, EDMOND EARL (DC)
Entity type:Individual
Prefix:DR
First Name:EDMOND
Middle Name:EARL
Last Name:HATTAWAY
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:PO BOX 1171
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-1171
Mailing Address - Country:US
Mailing Address - Phone:770-489-0187
Mailing Address - Fax:770-920-0364
Practice Address - Street 1:2080 FAIRBURN ROAD
Practice Address - Street 2:SUITE F
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1064
Practice Address - Country:US
Practice Address - Phone:770-489-0187
Practice Address - Fax:770-920-0364
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA55001148AMedicaid
GA35ZCBWKMedicare ID - Type Unspecified
GA55001148AMedicaid