Provider Demographics
NPI:1255489712
Name:THACKER CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:THACKER CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MITCHEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:THACKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-860-8333
Mailing Address - Street 1:1815 HIGHWAY 138 SE
Mailing Address - Street 2:SUITE 600
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2079
Mailing Address - Country:US
Mailing Address - Phone:770-860-8333
Mailing Address - Fax:770-860-8833
Practice Address - Street 1:1815 HIGHWAY 138 SE
Practice Address - Street 2:SUITE 600
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2079
Practice Address - Country:US
Practice Address - Phone:770-860-8333
Practice Address - Fax:770-860-8833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002342111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty