Provider Demographics
NPI:1760674980
Name:MARIETTA SQUARE CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:MARIETTA SQUARE CHIROPRACTIC, INC.
Other - Org Name:CHIROPRACTIC CARE OF MARIETTA SQUARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TRENT
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BRUMBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:672-472-6262
Mailing Address - Street 1:487 ROSWELL ST NE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-2066
Mailing Address - Country:US
Mailing Address - Phone:770-428-4656
Mailing Address - Fax:
Practice Address - Street 1:487 ROSWELL ST NE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-2066
Practice Address - Country:US
Practice Address - Phone:770-428-4656
Practice Address - Fax:770-428-4956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-11
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6957111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJGCMedicare PIN