Provider Demographics
NPI:1821206368
Name:HEALTH FOR LIFE CHIROPRACTIC
Entity Type:Organization
Organization Name:HEALTH FOR LIFE CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDMOND
Authorized Official - Middle Name:E
Authorized Official - Last Name:HATTAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-489-0187
Mailing Address - Street 1:POBOX 1171
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30133-1171
Mailing Address - Country:US
Mailing Address - Phone:770-489-0187
Mailing Address - Fax:770-920-0364
Practice Address - Street 1:2080 FAIRBURN RD
Practice Address - Street 2:STE F
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135
Practice Address - Country:US
Practice Address - Phone:770-489-0187
Practice Address - Fax:770-920-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA=========Medicare UPIN
GA35ZCBWKMedicare ID - Type Unspecified