Provider Demographics
NPI:1770508145
Name:GREEN, STEPHEN KELLY (DC)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:KELLY
Last Name:GREEN
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 1:4200 WADE GREEN RD NW
Mailing Address - Street 2:SUITE 27
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-1237
Mailing Address - Country:US
Mailing Address - Phone:770-427-2799
Mailing Address - Fax:770-427-2243
Practice Address - Street 1:4200 WADE GREEN RD NW
Practice Address - Street 2:SUITE 27
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-1237
Practice Address - Country:US
Practice Address - Phone:770-427-2799
Practice Address - Fax:770-427-2243
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO02560111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor