Provider Demographics
NPI:1114381175
Name:FAYETTE CHIROPRACTIC CENTER, INC
Entity Type:Organization
Organization Name:FAYETTE CHIROPRACTIC CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:H
Authorized Official - Last Name:KATZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-461-2225
Mailing Address - Street 1:1905 WINDHAM PARK NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30324-4960
Mailing Address - Country:US
Mailing Address - Phone:404-384-3312
Mailing Address - Fax:404-875-7961
Practice Address - Street 1:7208 TARA BLVD
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1902
Practice Address - Country:US
Practice Address - Phone:770-461-2225
Practice Address - Fax:404-875-7961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-06
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA070429854AMedicare UPIN