Provider Demographics
NPI:1093962540
Name:VILLAGE CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:VILLAGE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-469-7330
Mailing Address - Street 1:2045 ROCKBRIDGE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3551
Mailing Address - Country:US
Mailing Address - Phone:770-469-7330
Mailing Address - Fax:770-469-9588
Practice Address - Street 1:2045 ROCKBRIDGE RD
Practice Address - Street 2:STE 101
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3551
Practice Address - Country:US
Practice Address - Phone:770-469-7330
Practice Address - Fax:770-469-9588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO05997111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty