Provider Demographics
NPI:1942486501
Name:FORTIN, DANIEL PATRIC (DC)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:PATRIC
Last Name:FORTIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 E FREEWAY DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5927
Mailing Address - Country:US
Mailing Address - Phone:770-760-0060
Mailing Address - Fax:770-760-0409
Practice Address - Street 1:1003 E FREEWAY DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5927
Practice Address - Country:US
Practice Address - Phone:770-760-0060
Practice Address - Fax:770-760-0409
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1411111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00395570OtherMEDICARE RAILROAD
GA35ZCBDSMedicare PIN
GAU35977Medicare UPIN