Provider Demographics
NPI:1003093543
Name:GREGORY, LADARIAN SHAWNTELL (DC)
Entity Type:Individual
Prefix:
First Name:LADARIAN
Middle Name:SHAWNTELL
Last Name:GREGORY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2853 CANDLER RD STE 5
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1421
Mailing Address - Country:US
Mailing Address - Phone:678-612-7137
Mailing Address - Fax:404-212-7694
Practice Address - Street 1:2853 CANDLER RD STE 5
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1421
Practice Address - Country:US
Practice Address - Phone:678-612-7137
Practice Address - Fax:404-212-7694
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007452111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor