Provider Demographics
NPI:1720424310
Name:GEORGIA GWINNETT CLINIC
Entity type:Organization
Organization Name:GEORGIA GWINNETT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BYUNG
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:678-587-5390
Mailing Address - Street 1:2856 BUFORD HIGHWAY
Mailing Address - Street 2:SUITE 7
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096
Mailing Address - Country:US
Mailing Address - Phone:678-587-5390
Mailing Address - Fax:678-587-5314
Practice Address - Street 1:2856 BUFORD HIGHWAY
Practice Address - Street 2:SUITE 7
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096
Practice Address - Country:US
Practice Address - Phone:678-587-5390
Practice Address - Fax:678-587-5314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008710111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty