Provider Demographics
NPI:1275276271
Name:RODRIGUEZ GOIRE, IVAN CAMILO (DC)
Entity Type:Individual
Prefix:DR
First Name:IVAN
Middle Name:CAMILO
Last Name:RODRIGUEZ GOIRE
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 1:1197 FLAMINGO DR
Mailing Address - Street 2:
Mailing Address - City:AUSTELL
Mailing Address - State:GA
Mailing Address - Zip Code:30168-6109
Mailing Address - Country:US
Mailing Address - Phone:404-857-9742
Mailing Address - Fax:
Practice Address - Street 1:1245 VETERAN MEMORIAL HWY SW
Practice Address - Street 2:SUITE 22
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:404-964-4985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010018111NN0400X, 111NR0200X, 111NR0400X, 111NX0800X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NN0400XChiropractic ProvidersChiropractorNeurology
No111NR0200XChiropractic ProvidersChiropractorRadiology
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NX0800XChiropractic ProvidersChiropractorOrthopedic