Provider Demographics
NPI:1568708600
Name:MITCHELL STREET CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:MITCHELL STREET CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MIA
Authorized Official - Middle Name:YVETTE
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-927-9166
Mailing Address - Street 1:217 MITCHELL ST SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30303-3304
Mailing Address - Country:US
Mailing Address - Phone:678-927-9166
Mailing Address - Fax:678-609-5438
Practice Address - Street 1:217 MITCHELL ST SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30303-3304
Practice Address - Country:US
Practice Address - Phone:678-927-9166
Practice Address - Fax:678-609-5438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJJHMedicare UPIN
GAP00317925Medicare PIN