Provider Demographics
NPI:1427395755
Name:CONYERS CHIROPRACTIC & MASSAGE P.C.
Entity Type:Organization
Organization Name:CONYERS CHIROPRACTIC & MASSAGE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDNER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-922-8150
Mailing Address - Street 1:2239 GEORGIA HIGHWAY 20 SE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30013-2091
Mailing Address - Country:US
Mailing Address - Phone:770-922-8150
Mailing Address - Fax:770-922-8151
Practice Address - Street 1:2239 GEORGIA HIGHWAY 20 SE
Practice Address - Street 2:SUITE D
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2091
Practice Address - Country:US
Practice Address - Phone:770-922-8150
Practice Address - Fax:770-922-8151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007480111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U98611Medicare UPIN
35ZCJSXMedicare PIN