Provider Demographics
NPI:1871006270
Name:NIEVES, OMAR DAVID
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:DAVID
Last Name:NIEVES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 BROOKHAVEN CT
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-2189
Mailing Address - Country:US
Mailing Address - Phone:770-940-2255
Mailing Address - Fax:
Practice Address - Street 1:1301 SHILOH RD NW STE 811
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-7156
Practice Address - Country:US
Practice Address - Phone:770-940-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR009929111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor