Provider Demographics
NPI:1124603683
Name:DISBRO, DALE WESLEY JR (DC)
Entity Type:Individual
Prefix:DR
First Name:DALE
Middle Name:WESLEY
Last Name:DISBRO
Suffix:JR
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 1:2695 DELK RD SE APT C
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-6209
Mailing Address - Country:US
Mailing Address - Phone:151-767-7782
Mailing Address - Fax:
Practice Address - Street 1:1640 POWERS FERRY RD SE STE 175
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-5491
Practice Address - Country:US
Practice Address - Phone:770-690-8959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-16
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor