Provider Demographics
NPI:1760694483
Name:SELF ACTUALIZATION KINESIOLOGY
Entity Type:Organization
Organization Name:SELF ACTUALIZATION KINESIOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LINDSEY
Authorized Official - Last Name:FREY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:404-261-7504
Mailing Address - Street 1:455 EAST PACES FERRY ROAD
Mailing Address - Street 2:325
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305
Mailing Address - Country:US
Mailing Address - Phone:404-261-7504
Mailing Address - Fax:404-477-3291
Practice Address - Street 1:455 EAST PACES FERRY ROAD
Practice Address - Street 2:325
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30305
Practice Address - Country:US
Practice Address - Phone:404-261-7504
Practice Address - Fax:404-477-3291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2831111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty