Provider Demographics
NPI:1619389228
Name:VICKERY CHIROPRACTIC, LLC
Entity Type:Organization
Organization Name:VICKERY CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPLE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-947-4449
Mailing Address - Street 1:5830 CLARION ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30040-0380
Mailing Address - Country:US
Mailing Address - Phone:678-947-4449
Mailing Address - Fax:678-455-3655
Practice Address - Street 1:5830 CLARION ST
Practice Address - Street 2:STE 101
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-0380
Practice Address - Country:US
Practice Address - Phone:678-947-4449
Practice Address - Fax:678-455-3655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-30
Last Update Date:2014-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006074111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU97144Medicare UPIN