Provider Demographics
NPI:1629221213
Name:LIFE OF GEORGIA CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:LIFE OF GEORGIA CHIROPRACTIC CLINIC
Other - Org Name:LIFE OF GEORGIA CHIROPRACTIC CLINIC, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:O
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-733-2211
Mailing Address - Street 1:1914 CENTRAL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4126
Mailing Address - Country:US
Mailing Address - Phone:706-733-2211
Mailing Address - Fax:706-733-2271
Practice Address - Street 1:1914 CENTRAL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4126
Practice Address - Country:US
Practice Address - Phone:706-733-2211
Practice Address - Fax:706-733-2271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
GA1346261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1376788406OtherTHIRD PARTY