Provider Demographics
NPI:1699964171
Name:LOCUST GROVE CLINIC, P.C.
Entity type:Organization
Organization Name:LOCUST GROVE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:TULLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-898-0028
Mailing Address - Street 1:2648 HIGHWAY 42
Mailing Address - Street 2:
Mailing Address - City:LOCUST GROVE
Mailing Address - State:GA
Mailing Address - Zip Code:30248-2519
Mailing Address - Country:US
Mailing Address - Phone:770-898-0028
Mailing Address - Fax:770-898-7987
Practice Address - Street 1:2648 HIGHWAY 42
Practice Address - Street 2:
Practice Address - City:LOCUST GROVE
Practice Address - State:GA
Practice Address - Zip Code:30248-2519
Practice Address - Country:US
Practice Address - Phone:770-898-0028
Practice Address - Fax:770-898-7987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIROO6323111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4337OtherMEDICARE GROUP