Provider Demographics
NPI:1942577804
Name:FAIRBURN ROAD CHIROPRACTIC CLINIC, INC.
Entity Type:Organization
Organization Name:FAIRBURN ROAD CHIROPRACTIC CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:BAGGETT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-920-1707
Mailing Address - Street 1:2080 FAIRBURN RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1064
Mailing Address - Country:US
Mailing Address - Phone:770-920-1707
Mailing Address - Fax:770-920-0364
Practice Address - Street 1:2080 FAIRBURN RD
Practice Address - Street 2:SUITE F
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1064
Practice Address - Country:US
Practice Address - Phone:770-920-1707
Practice Address - Fax:770-920-0364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR 005501111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA464207Medicare UPIN