Provider Demographics
NPI:1194005082
Name:NORTHEAST CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:NORTHEAST CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LORI
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:UGOLIK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:478-743-2402
Mailing Address - Street 1:618 SHURLING DR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31211-1950
Mailing Address - Country:US
Mailing Address - Phone:478-743-2402
Mailing Address - Fax:
Practice Address - Street 1:618 SHURLING DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31211-1950
Practice Address - Country:US
Practice Address - Phone:478-743-2402
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-23
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR 005023261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center