Provider Demographics
NPI:1346452596
Name:LAGRANGE CLINIC OF CHIROPRACTIC INCORPORATED
Entity Type:Organization
Organization Name:LAGRANGE CLINIC OF CHIROPRACTIC INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:N
Authorized Official - Last Name:GARRISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-882-1000
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-0018
Mailing Address - Country:US
Mailing Address - Phone:706-882-1000
Mailing Address - Fax:
Practice Address - Street 1:403 RIDLEY AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-2231
Practice Address - Country:US
Practice Address - Phone:706-882-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007612111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7113Medicare ID - Type Unspecified