Provider Demographics
NPI:1699817767
Name:SANDY PLAINS CHIROPRACTIC CLINIC
Entity type:Organization
Organization Name:SANDY PLAINS CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALLOY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:770-971-1355
Mailing Address - Street 1:2697 SANDY PLAINS RD
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-4256
Mailing Address - Country:US
Mailing Address - Phone:770-971-1355
Mailing Address - Fax:770-509-8559
Practice Address - Street 1:2697 SANDY PLAINS RD
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-4256
Practice Address - Country:US
Practice Address - Phone:770-971-1355
Practice Address - Fax:770-509-8559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2012-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR004699111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU29810Medicare UPIN
GA35ZCBZCMedicare ID - Type Unspecified