Provider Demographics
NPI:1699938514
Name:STUCKEY CLINIC OF CHIROPRACTIC
Entity type:Organization
Organization Name:STUCKEY CLINIC OF CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ORVILLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:STUCKEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:706-517-0419
Mailing Address - Street 1:2557 HIGHWAY 76
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30705-7311
Mailing Address - Country:US
Mailing Address - Phone:706-517-0419
Mailing Address - Fax:706-517-0420
Practice Address - Street 1:2557 HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:GA
Practice Address - Zip Code:30705-7311
Practice Address - Country:US
Practice Address - Phone:706-517-0419
Practice Address - Fax:706-517-0420
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-10
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007582111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJHVMedicare PIN
GAV00870Medicare UPIN