Provider Demographics
NPI:1699953414
Name:BANKHEAD CHIROPRACTIC
Entity type:Organization
Organization Name:BANKHEAD CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:B
Authorized Official - Last Name:DUVERNEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-459-0035
Mailing Address - Street 1:514 W BANKHEAD HWY
Mailing Address - Street 2:#300
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-1736
Mailing Address - Country:US
Mailing Address - Phone:770-838-5577
Mailing Address - Fax:770-456-6174
Practice Address - Street 1:514 W BANKHEAD HWY
Practice Address - Street 2:#300
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1736
Practice Address - Country:US
Practice Address - Phone:770-459-0035
Practice Address - Fax:770-456-6174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-04
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA006621111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU64601Medicare UPIN
GA35ZCJSVMedicare PIN