Provider Demographics
NPI:1235220633
Name:GREEN, HEIDI (DC)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:GREEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 BRASELTON HWY BLDG F
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-1027
Mailing Address - Country:US
Mailing Address - Phone:770-614-6630
Mailing Address - Fax:770-614-6684
Practice Address - Street 1:3509 BRASELTON HWY BLDG F
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-1027
Practice Address - Country:US
Practice Address - Phone:770-614-6630
Practice Address - Fax:770-614-6684
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007637111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHZXMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER