Provider Demographics
NPI:1689979650
Name:PORT, WADE (DC)
Entity Type:Individual
Prefix:DR
First Name:WADE
Middle Name:
Last Name:PORT
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 JOHNSON FERRY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-8309
Mailing Address - Country:US
Mailing Address - Phone:678-926-9300
Mailing Address - Fax:
Practice Address - Street 1:2840 JOHNSON FERRY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-8309
Practice Address - Country:US
Practice Address - Phone:678-926-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008769111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor