Provider Demographics
NPI:1538478508
Name:GEORGIA CLINIC OF CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:GEORGIA CLINIC OF CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:HUNTSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-922-2948
Mailing Address - Street 1:205 OLD BLACKSTONE CAMP RD
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-9459
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 OLD BLACKSTONE CAMP RD
Practice Address - Street 2:
Practice Address - City:MARTINEZ
Practice Address - State:GA
Practice Address - Zip Code:30907-9459
Practice Address - Country:US
Practice Address - Phone:618-922-2948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008712111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty