Provider Demographics
NPI:1376872184
Name:MARIETTA HEALTHCARE
Entity Type:Organization
Organization Name:MARIETTA HEALTHCARE
Other - Org Name:SOUTHERN HEALTHCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NELSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MEDRANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-792-0927
Mailing Address - Street 1:PO BOX 6881
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30065-0881
Mailing Address - Country:US
Mailing Address - Phone:770-792-0927
Mailing Address - Fax:770-792-7893
Practice Address - Street 1:534 FLINT TRL
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1316
Practice Address - Country:US
Practice Address - Phone:770-792-0927
Practice Address - Fax:770-792-7893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-08
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty