Provider Demographics
NPI:1629264072
Name:DCLC TWO PC
Entity Type:Organization
Organization Name:DCLC TWO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:CURTIS
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDORCHUK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-864-5362
Mailing Address - Street 1:PO BOX 599
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-0010
Mailing Address - Country:US
Mailing Address - Phone:706-864-5362
Mailing Address - Fax:706-864-5761
Practice Address - Street 1:131 MECHANIC ST
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1337
Practice Address - Country:US
Practice Address - Phone:706-864-5362
Practice Address - Fax:706-864-5761
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07276111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA389233OtherBCBS
GADF0709OtherMEDICARE RAILROAD
GAGRP6904OtherMEDICARE
GAU94034Medicare UPIN