Provider Demographics
NPI:1790017457
Name:BLACK, PAIGE M (DC)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:M
Last Name:BLACK
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 1:1066 KILLIAN HILL RD SW
Mailing Address - Street 2:SUITE 103
Mailing Address - City:LILBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30047-2306
Mailing Address - Country:US
Mailing Address - Phone:770-921-2830
Mailing Address - Fax:770-921-2836
Practice Address - Street 1:1066 KILLIAN HILL RD SW
Practice Address - Street 2:SUITE 103
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047-2306
Practice Address - Country:US
Practice Address - Phone:770-921-2830
Practice Address - Fax:770-921-2836
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008448111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor