Provider Demographics
NPI:1194024927
Name:BONNER, BRIAN KEITH (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:BONNER
Suffix:
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 1:125 EAGLE SPRING DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-6328
Mailing Address - Country:US
Mailing Address - Phone:678-379-0943
Mailing Address - Fax:678-379-0945
Practice Address - Street 1:125 EAGLE SPRING DR
Practice Address - Street 2:SUITE C
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-6328
Practice Address - Country:US
Practice Address - Phone:678-379-0943
Practice Address - Fax:678-379-0945
Is Sole Proprietor?:No
Enumeration Date:2011-03-18
Last Update Date:2011-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006388111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor