Provider Demographics
NPI:1528387214
Name:VIDA CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:VIDA CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER/REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIELA
Authorized Official - Middle Name:B
Authorized Official - Last Name:PEROSINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-451-8871
Mailing Address - Street 1:611-A HOLCOMB BRIDGE RD.
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-1768
Mailing Address - Country:US
Mailing Address - Phone:678-451-8871
Mailing Address - Fax:
Practice Address - Street 1:611 HOLCOMB BRIDGE RD STE A
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1769
Practice Address - Country:US
Practice Address - Phone:678-451-8871
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-20
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007819111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty