Provider Demographics
NPI:1497970024
Name:TARA CHIROPRACTIC CARE CENTER, LLC
Entity Type:Organization
Organization Name:TARA CHIROPRACTIC CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CARYN
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GRZESIAKOWSKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-478-6040
Mailing Address - Street 1:PO BOX 1378
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30214-6378
Mailing Address - Country:US
Mailing Address - Phone:770-478-6040
Mailing Address - Fax:770-478-6061
Practice Address - Street 1:809 FLINT RIVER RD STE 4
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30238-4342
Practice Address - Country:US
Practice Address - Phone:770-478-6040
Practice Address - Fax:770-478-6061
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006958111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU87293Medicare UPIN
GA35ZCGNQMedicare ID - Type UnspecifiedINDIVIDUAL #
GAGRP4208Medicare ID - Type Unspecified