Provider Demographics
NPI:1790845857
Name:LIGHTHOUSE CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:LIGHTHOUSE CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-503-0500
Mailing Address - Street 1:3458 WINDER HWY
Mailing Address - Street 2:SUITE 120
Mailing Address - City:FLOWERY BRANCH
Mailing Address - State:GA
Mailing Address - Zip Code:30542-3007
Mailing Address - Country:US
Mailing Address - Phone:770-503-0500
Mailing Address - Fax:770-503-0635
Practice Address - Street 1:3458 WINDER HWY
Practice Address - Street 2:SUITE 120
Practice Address - City:FLOWERY BRANCH
Practice Address - State:GA
Practice Address - Zip Code:30542-3007
Practice Address - Country:US
Practice Address - Phone:770-503-0500
Practice Address - Fax:770-503-0635
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006987111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1669443859OtherNPI TYPE 1 NUMBER
GAGRP7297Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
GA1669443859OtherNPI TYPE 1 NUMBER