Provider Demographics
NPI:1528152402
Name:FT VALLEY CHIROPRACTIC CLINIC PC
Entity type:Organization
Organization Name:FT VALLEY CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:SHARPE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:478-825-2941
Mailing Address - Street 1:204 NORTH CAMELLIA BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:FORT VALLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31030-3005
Mailing Address - Country:US
Mailing Address - Phone:478-825-2941
Mailing Address - Fax:478-825-0495
Practice Address - Street 1:204 NORTH CAMELLIA BOULEVARD
Practice Address - Street 2:
Practice Address - City:FORT VALLEY
Practice Address - State:GA
Practice Address - Zip Code:31030-3005
Practice Address - Country:US
Practice Address - Phone:478-825-2941
Practice Address - Fax:478-825-0495
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR003070111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00590312AMedicaid
GA35ZCHPRMedicare ID - Type Unspecified
GA00590312AMedicaid