Provider Demographics
NPI:1528495207
Name:FAMILY TREE CHIROPRACTIC PLLC
Entity type:Organization
Organization Name:FAMILY TREE CHIROPRACTIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BUNGE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:734-765-9448
Mailing Address - Street 1:3988 LLEWELLIN LN SW
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-3557
Mailing Address - Country:US
Mailing Address - Phone:734-765-9448
Mailing Address - Fax:
Practice Address - Street 1:3988 LLEWELLIN LN SW
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-3557
Practice Address - Country:US
Practice Address - Phone:734-765-9448
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-26
Last Update Date:2013-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty