Provider Demographics
NPI:1699859637
Name:MORIBALDI, MICHAEL J (DC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MORIBALDI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4343 SHALLOWFORD RD
Mailing Address - Street 2:SUITE B6
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5023
Mailing Address - Country:US
Mailing Address - Phone:770-649-1730
Mailing Address - Fax:770-649-1731
Practice Address - Street 1:4343 SHALLOWFORD RD
Practice Address - Street 2:SUITE B6
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5023
Practice Address - Country:US
Practice Address - Phone:770-649-1730
Practice Address - Fax:770-649-1731
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA005452111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDJRMedicare UPIN