Provider Demographics
NPI:1114461852
Name:GEORGIA CHIROPRACTIC NEUROLOGY CENTER LLC
Entity Type:Organization
Organization Name:GEORGIA CHIROPRACTIC NEUROLOGY CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-259-3365
Mailing Address - Street 1:903 BOMBAY LN
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-5829
Mailing Address - Country:US
Mailing Address - Phone:770-664-4288
Mailing Address - Fax:
Practice Address - Street 1:903 BOMBAY LN
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-5829
Practice Address - Country:US
Practice Address - Phone:770-664-4288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO07215111NN0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NN0400XChiropractic ProvidersChiropractorNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGZNMedicare PIN