Provider Demographics
NPI:1275878381
Name:CEDARCREST MEDICAL AND REHABILITATION
Entity Type:Organization
Organization Name:CEDARCREST MEDICAL AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:BUENO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-574-4878
Mailing Address - Street 1:2161 CEDARCREST RD
Mailing Address - Street 2:115
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30101-6404
Mailing Address - Country:US
Mailing Address - Phone:678-574-4878
Mailing Address - Fax:678-574-4899
Practice Address - Street 1:2161 CEDARCREST RD
Practice Address - Street 2:115
Practice Address - City:ACWORTH
Practice Address - State:GA
Practice Address - Zip Code:30101-6404
Practice Address - Country:US
Practice Address - Phone:678-574-4878
Practice Address - Fax:678-574-4899
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007057111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1114078474Medicare PIN