Provider Demographics
NPI:1760501217
Name:MOLLARD, MICHELLE LEE (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:LEE
Last Name:MOLLARD
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1159 JAMES BURGESS RD
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-1124
Mailing Address - Country:US
Mailing Address - Phone:678-205-0637
Mailing Address - Fax:
Practice Address - Street 1:11180 STATE BRIDGE RD
Practice Address - Street 2:SUITE 402
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-7482
Practice Address - Country:US
Practice Address - Phone:678-205-0637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007173111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV01388Medicare UPIN