Provider Demographics
NPI:1922232628
Name:HEALTHY LIVING CHIROPRACTIC AND WELLNESS CENTER, INC
Entity Type:Organization
Organization Name:HEALTHY LIVING CHIROPRACTIC AND WELLNESS CENTER, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAUNNA
Authorized Official - Middle Name:TENNISE
Authorized Official - Last Name:MORROW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-469-7330
Mailing Address - Street 1:2045 ROCKBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-3551
Mailing Address - Country:US
Mailing Address - Phone:770-469-7330
Mailing Address - Fax:770-469-9588
Practice Address - Street 1:2045 ROCKBRIDGE RD
Practice Address - Street 2:BUILDING 500 SUITE 225
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30087-3551
Practice Address - Country:US
Practice Address - Phone:770-469-7330
Practice Address - Fax:770-496-9588
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HEALTHY LIVING CHIROPRACTIC AND WELLNESS CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-08
Last Update Date:2015-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA07654302F00000X, 302R00000X, 305R00000X, 305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
No302F00000XManaged Care OrganizationsExclusive Provider Organization
No305R00000XManaged Care OrganizationsPreferred Provider Organization
No305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV08905Medicare UPIN