Provider Demographics
NPI:1508190364
Name:OPTIMAL BODY CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:OPTIMAL BODY CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOLDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-805-1235
Mailing Address - Street 1:431 W PONCE DE LEON AVE
Mailing Address - Street 2:SUITE 7
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2458
Mailing Address - Country:US
Mailing Address - Phone:404-805-1235
Mailing Address - Fax:
Practice Address - Street 1:431 W PONCE DE LEON AVE
Practice Address - Street 2:SUITE 7
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2458
Practice Address - Country:US
Practice Address - Phone:404-805-1235
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008037111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty