Provider Demographics
NPI:1790945475
Name:FULL BODY REJUVENETION CENTER, LLC
Entity Type:Organization
Organization Name:FULL BODY REJUVENETION CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NAILAH
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-613-4650
Mailing Address - Street 1:3636 PANOLA RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30038-2733
Mailing Address - Country:US
Mailing Address - Phone:678-609-1586
Mailing Address - Fax:
Practice Address - Street 1:3636 PANOLA RD
Practice Address - Street 2:SUITE B
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30038-2733
Practice Address - Country:US
Practice Address - Phone:678-609-1586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-16
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty