Provider Demographics
NPI:1730287582
Name:ALPHARETTA BACK AND NECK CENTER
Entity Type:Organization
Organization Name:ALPHARETTA BACK AND NECK CENTER
Other - Org Name:ALPHARETTA BACK AND NECK CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DC OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIVAGNO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:251-610-9614
Mailing Address - Street 1:3502 OLD MILTON PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4458
Mailing Address - Country:US
Mailing Address - Phone:251-610-9614
Mailing Address - Fax:770-997-1599
Practice Address - Street 1:3502 OLD MILTON PKWY
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30005-4458
Practice Address - Country:US
Practice Address - Phone:251-610-9614
Practice Address - Fax:770-997-1599
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA1707111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========OtherTAX ID
GAU86698Medicare UPIN