Provider Demographics
NPI:1083666739
Name:TALLEY, GREGORY BENTON (DC)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:BENTON
Last Name:TALLEY
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 1:1544 PIEDMONT AVE NE STE 109
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-5018
Mailing Address - Country:US
Mailing Address - Phone:404-892-8191
Mailing Address - Fax:404-892-8197
Practice Address - Street 1:1544 PIEDMONT AVE NE STE 109
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30324-5018
Practice Address - Country:US
Practice Address - Phone:404-892-8191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA2913111NX0800X
GA2913111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU12420Medicare UPIN
GA35ZCBPBMedicare ID - Type Unspecified