Provider Demographics
NPI:1518919026
Name:BUBOLO, VINCENT C (DC)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:C
Last Name:BUBOLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3195 ACWORTH DUE WEST RD NW
Mailing Address - Street 2:STE. B
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-2313
Mailing Address - Country:US
Mailing Address - Phone:770-975-1299
Mailing Address - Fax:770-975-1361
Practice Address - Street 1:3195 ACWORTH DUE WEST RD NW
Practice Address - Street 2:STE. B
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30152-2313
Practice Address - Country:US
Practice Address - Phone:770-975-1299
Practice Address - Fax:770-975-1361
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6956111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGLJMedicare ID - Type UnspecifiedPROVIDER NUMBER