Provider Demographics
NPI:1598868416
Name:EASTSIDE CHIROPRACTIC
Entity Type:Organization
Organization Name:EASTSIDE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:HOOPER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-310-1121
Mailing Address - Street 1:1011 WOODRIDGE LANE
Mailing Address - Street 2:BLDG. 301
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6077
Mailing Address - Country:US
Mailing Address - Phone:706-310-1121
Mailing Address - Fax:706-310-1165
Practice Address - Street 1:1011 WOODRIDGE LANE
Practice Address - Street 2:BLDG. 301
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6077
Practice Address - Country:US
Practice Address - Phone:706-310-1121
Practice Address - Fax:706-310-1165
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6752111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGRZMedicare ID - Type UnspecifiedCHIROPRACTIC