Provider Demographics
NPI:1427224724
Name:EAGLE CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:EAGLE CHIROPRACTIC CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-565-1500
Mailing Address - Street 1:616 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE-10
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-5096
Mailing Address - Country:US
Mailing Address - Phone:678-565-1500
Mailing Address - Fax:678-565-7411
Practice Address - Street 1:616 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE-10
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5096
Practice Address - Country:US
Practice Address - Phone:678-565-1500
Practice Address - Fax:678-565-7411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-06
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACH7373111NI0013X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0013XChiropractic ProvidersChiropractorIndependent Medical ExaminerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHHBMedicare PIN
GAU95337Medicare UPIN
GA35ZCHGGMedicare PIN
GAU84329Medicare UPIN