Provider Demographics
NPI:1093810020
Name:HEALTHSOURCE CHIROPRACTIC OF JOHNS CREEK
Entity Type:Organization
Organization Name:HEALTHSOURCE CHIROPRACTIC OF JOHNS CREEK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:WEST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-957-0266
Mailing Address - Street 1:10475 MEDLOCK BRIDGE RD
Mailing Address - Street 2:SUITE #810
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-4433
Mailing Address - Country:US
Mailing Address - Phone:678-957-0266
Mailing Address - Fax:678-957-0268
Practice Address - Street 1:10475 MEDLOCK BRIDGE RD
Practice Address - Street 2:SUITE #810
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30097-4433
Practice Address - Country:US
Practice Address - Phone:678-957-0266
Practice Address - Fax:678-957-0268
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO003079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCCBJMedicare ID - Type Unspecified