Provider Demographics
NPI:1265659155
Name:FAMILY LIFE CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:FAMILY LIFE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-632-2707
Mailing Address - Street 1:PO BOX 2671
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-0047
Mailing Address - Country:US
Mailing Address - Phone:706-632-2707
Mailing Address - Fax:706-632-2723
Practice Address - Street 1:351 E HIGHLAND ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4544
Practice Address - Country:US
Practice Address - Phone:706-632-2707
Practice Address - Fax:706-632-2723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP3939Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER