Provider Demographics
NPI:1912025727
Name:SKELTON, MARY LOU (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY LOU
Middle Name:
Last Name:SKELTON
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 1:2151 FOUNTAIN DR
Mailing Address - Street 2:SUITE #105
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6783
Mailing Address - Country:US
Mailing Address - Phone:770-972-4408
Mailing Address - Fax:770-972-6873
Practice Address - Street 1:2151 FOUNTAIN DR
Practice Address - Street 2:SUITE #105
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6783
Practice Address - Country:US
Practice Address - Phone:770-972-4408
Practice Address - Fax:770-972-6873
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO06390111N00000X
TX57858111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGFZMedicare ID - Type Unspecified
GAU79394Medicare UPIN