Provider Demographics
NPI:1396016648
Name:LARGE, DUSTY (DC)
Entity Type:Individual
Prefix:DR
First Name:DUSTY
Middle Name:
Last Name:LARGE
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 1:4931 RIVERSIDE DR STE 300A
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-1168
Mailing Address - Country:US
Mailing Address - Phone:478-257-6114
Mailing Address - Fax:478-238-5415
Practice Address - Street 1:4931 RIVERSIDE DR STE 300A
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-1168
Practice Address - Country:US
Practice Address - Phone:478-257-6114
Practice Address - Fax:478-238-5415
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008931111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor