Provider Demographics
NPI:1598998510
Name:TODD SUPNICK DC PC
Entity Type:Organization
Organization Name:TODD SUPNICK DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SUPNICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-262-1909
Mailing Address - Street 1:2829 DALLAS ST
Mailing Address - Street 2:STE B
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-2722
Mailing Address - Country:US
Mailing Address - Phone:770-262-1909
Mailing Address - Fax:
Practice Address - Street 1:2829 DALLAS ST
Practice Address - Street 2:STE B
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-2722
Practice Address - Country:US
Practice Address - Phone:770-262-1909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-25
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty