Provider Demographics
NPI:1710059498
Name:THACKER, MITCHEL L (DC)
Entity Type:Individual
Prefix:DR
First Name:MITCHEL
Middle Name:L
Last Name:THACKER
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 1:2575 ABBEY RIDGE RD SW
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3459
Mailing Address - Country:US
Mailing Address - Phone:770-860-8333
Mailing Address - Fax:770-860-8833
Practice Address - Street 1:1815 HIGHWAY 138 SE
Practice Address - Street 2:SUITE 600
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2079
Practice Address - Country:US
Practice Address - Phone:770-860-8333
Practice Address - Fax:770-860-8833
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002342111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU22579Medicare UPIN
GA35ZCCPWMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER