Provider Demographics
NPI:1609064716
Name:PROCTOR CLINIC PC
Entity Type:Organization
Organization Name:PROCTOR CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:PROCTOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-383-9605
Mailing Address - Street 1:PO BOX 200066
Mailing Address - Street 2:
Mailing Address - City:CARTERSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30120-9002
Mailing Address - Country:US
Mailing Address - Phone:770-383-9605
Mailing Address - Fax:770-383-9606
Practice Address - Street 1:1010 N TENNESSEE ST
Practice Address - Street 2:SUITE 116
Practice Address - City:CARTERSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30120-8525
Practice Address - Country:US
Practice Address - Phone:770-383-9605
Practice Address - Fax:770-383-9606
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIROOO514111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGFMMedicare PIN