Provider Demographics
NPI:1245395516
Name:IMBESI, ANTHONY LOUIS JR (DC)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:LOUIS
Last Name:IMBESI
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:PO BOX 461
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-0012
Mailing Address - Country:US
Mailing Address - Phone:706-782-2466
Mailing Address - Fax:
Practice Address - Street 1:6495 SHILOH RD
Practice Address - Street 2:UNIT 110
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-1635
Practice Address - Country:US
Practice Address - Phone:706-490-9230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5236111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00760625AMedicaid
NC89085H3Medicaid
GA35ZCDSPMedicare ID - Type Unspecified
GA00760625AMedicaid