Provider Demographics
NPI:1952678138
Name:CHIROPRACTIC CLINIC OF SNELLVILLE, INC.
Entity Type:Organization
Organization Name:CHIROPRACTIC CLINIC OF SNELLVILLE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:SIERADZKI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-982-5155
Mailing Address - Street 1:2331 HENRY CLOWER BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-3158
Mailing Address - Country:US
Mailing Address - Phone:770-982-5155
Mailing Address - Fax:770-982-4262
Practice Address - Street 1:2331 HENRY CLOWER BLVD STE C
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-3158
Practice Address - Country:US
Practice Address - Phone:770-982-5155
Practice Address - Fax:770-982-4262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-16
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR002081111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCHFFOtherMEDICARE ID
GA35ZCHFFOtherMEDICARE ID