Provider Demographics
NPI:1376916452
Name:CREEKSIDE CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:CREEKSIDE CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:IVY
Authorized Official - Last Name:JAMES
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-744-8393
Mailing Address - Street 1:5947 HOLLY SPRINGS PKWY
Mailing Address - Street 2:SUITE 308
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30188-2447
Mailing Address - Country:US
Mailing Address - Phone:770-744-8393
Mailing Address - Fax:
Practice Address - Street 1:5947 HOLLY SPRINGS PKWY
Practice Address - Street 2:SUITE 308
Practice Address - City:HOLLY SPRINGS
Practice Address - State:GA
Practice Address - Zip Code:30188-2447
Practice Address - Country:US
Practice Address - Phone:770-744-8393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-11
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006622111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I354499OtherMEDICARE PTAN
GA202I358649OtherMEDICARE