Provider Demographics
NPI:1003039611
Name:PEROSINO, MARIELA BETINA (DC)
Entity Type:Individual
Prefix:DR
First Name:MARIELA
Middle Name:BETINA
Last Name:PEROSINO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1769
Mailing Address - Country:US
Mailing Address - Phone:678-205-8432
Mailing Address - Fax:678-205-8443
Practice Address - Street 1:611 HOLCOMB BRIDGE RD
Practice Address - Street 2:STE A
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1769
Practice Address - Country:US
Practice Address - Phone:678-205-8432
Practice Address - Fax:678-205-8443
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor