Provider Demographics
NPI:1417015389
Name:PETITT, JAMES GREGORY (DC)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:GREGORY
Last Name:PETITT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:MR
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:PETITT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:426 WEST KYTLE STREET
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:GA
Mailing Address - Zip Code:30528-1336
Mailing Address - Country:US
Mailing Address - Phone:706-219-2317
Mailing Address - Fax:706-219-2317
Practice Address - Street 1:426 WEST KYTLE STREET
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:GA
Practice Address - Zip Code:30528-1336
Practice Address - Country:US
Practice Address - Phone:706-219-2317
Practice Address - Fax:706-219-2317
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO05932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U68149Medicare UPIN
GA35ZCDZXMedicare ID - Type Unspecified