Provider Demographics
NPI:1306197892
Name:BLUE RIDGE CHIROPRACTIC AND LIFE CENTER
Entity Type:Organization
Organization Name:BLUE RIDGE CHIROPRACTIC AND LIFE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:S
Authorized Official - Last Name:FUZI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-946-1215
Mailing Address - Street 1:5 W FAIN ST
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-4451
Mailing Address - Country:US
Mailing Address - Phone:706-946-1215
Mailing Address - Fax:706-946-1216
Practice Address - Street 1:5 W FAIN ST
Practice Address - Street 2:
Practice Address - City:BLUE RIDGE
Practice Address - State:GA
Practice Address - Zip Code:30513-4451
Practice Address - Country:US
Practice Address - Phone:706-946-1215
Practice Address - Fax:706-946-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-25
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO08129111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty