Provider Demographics
NPI:1518199165
Name:GEORGIA CHIROPRACTIC GROUP AT SIXES
Entity Type:Organization
Organization Name:GEORGIA CHIROPRACTIC GROUP AT SIXES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:LECROY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-720-1388
Mailing Address - Street 1:3542 SIXES RD
Mailing Address - Street 2:STE 100
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-9124
Mailing Address - Country:US
Mailing Address - Phone:770-720-1388
Mailing Address - Fax:770-720-1389
Practice Address - Street 1:3542 SIXES RD
Practice Address - Street 2:STE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-8961
Practice Address - Country:US
Practice Address - Phone:770-720-1388
Practice Address - Fax:770-720-1389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2012-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty