Provider Demographics
NPI:1669665030
Name:PEACHTREE CITY CHIROPRACTIC
Entity Type:Organization
Organization Name:PEACHTREE CITY CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAROLD
Authorized Official - Middle Name:CLIFFORD
Authorized Official - Last Name:BOST
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:770-631-3822
Mailing Address - Street 1:1117 CROSSTOWN CT.
Mailing Address - Street 2:
Mailing Address - City:PEACHTREE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30269-2951
Mailing Address - Country:US
Mailing Address - Phone:770-631-3822
Mailing Address - Fax:770-486-3515
Practice Address - Street 1:1117 CROSSTOWN CT.
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-2951
Practice Address - Country:US
Practice Address - Phone:770-631-3822
Practice Address - Fax:770-486-3515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-20
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR004673111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4707Medicare UPIN