Provider Demographics
NPI:1639371917
Name:GIDEON CHIROPRACTIC INCORPORATED
Entity Type:Organization
Organization Name:GIDEON CHIROPRACTIC INCORPORATED
Other - Org Name:ATLAS INJURY CHIROPRACTIC CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DURIE
Authorized Official - Middle Name:DELANO
Authorized Official - Last Name:HUMBER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:770-389-4724
Mailing Address - Street 1:165 BURKE ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-3463
Mailing Address - Country:US
Mailing Address - Phone:770-389-4724
Mailing Address - Fax:678-272-4031
Practice Address - Street 1:165 BURKE ST
Practice Address - Street 2:SUITE 105
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281
Practice Address - Country:US
Practice Address - Phone:770-389-4724
Practice Address - Fax:678-272-4031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005325111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA664098OtherUHC
GA664098OtherUHC