Provider Demographics
NPI:1275738296
Name:BANGUILAN, TONY (DC)
Entity Type:Individual
Prefix:DR
First Name:TONY
Middle Name:
Last Name:BANGUILAN
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 1:960 HERRINGTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-7212
Mailing Address - Country:US
Mailing Address - Phone:770-963-5585
Mailing Address - Fax:770-682-7636
Practice Address - Street 1:960 HERRINGTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-7212
Practice Address - Country:US
Practice Address - Phone:770-963-5585
Practice Address - Fax:770-682-7636
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006452111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJMZMedicare ID - Type Unspecified