Provider Demographics
NPI:1972642296
Name:FOURRE, TERESA GRACE (DC, CNMT)
Entity Type:Individual
Prefix:DR
First Name:TERESA
Middle Name:GRACE
Last Name:FOURRE
Suffix:
Gender:F
Credentials:DC, CNMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 489
Mailing Address - Street 2:
Mailing Address - City:HOLLY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30142-0009
Mailing Address - Country:US
Mailing Address - Phone:770-345-7885
Mailing Address - Fax:770-345-7883
Practice Address - Street 1:4080 HOLLY SPRINGS PKWY
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-7410
Practice Address - Country:US
Practice Address - Phone:770-345-7885
Practice Address - Fax:770-345-7883
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006079111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA52726673OtherBLUE CROSS BLUE SHIELD #
GA35ZCFVJMedicare ID - Type UnspecifiedMEDICARE PROVIDER