Provider Demographics
NPI:1609096213
Name:SELANO CHIROPRACTIC CENTER, INC.
Entity Type:Organization
Organization Name:SELANO CHIROPRACTIC CENTER, INC.
Other - Org Name:REGEN OSTEO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:L
Authorized Official - Last Name:SELANO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-445-1362
Mailing Address - Street 1:PO BOX 419
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:GA
Mailing Address - Zip Code:30132-0008
Mailing Address - Country:US
Mailing Address - Phone:770-445-1362
Mailing Address - Fax:770-445-5860
Practice Address - Street 1:243 MERCHANTS DRIVE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:GA
Practice Address - Zip Code:30132
Practice Address - Country:US
Practice Address - Phone:770-445-1362
Practice Address - Fax:770-445-5860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005181111N00000X
111N00000X, 207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCCSKMedicare ID - Type Unspecified
GAU50792Medicare UPIN