Provider Demographics
NPI:1316024136
Name:EASTER, GARY LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:LEE
Last Name:EASTER
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 1:125 COMMONS WAY STE 107
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-7041
Mailing Address - Country:US
Mailing Address - Phone:770-456-0160
Mailing Address - Fax:770-456-0823
Practice Address - Street 1:207 BERKLEY DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-2411
Practice Address - Country:US
Practice Address - Phone:770-456-0160
Practice Address - Fax:770-456-0823
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007036111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU92432Medicare UPIN
GA35ZCHCCMedicare ID - Type Unspecified