Provider Demographics
NPI:1972647089
Name:KERRY ELLIOTT DC PC
Entity Type:Organization
Organization Name:KERRY ELLIOTT DC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:KERRY
Authorized Official - Last Name:ELLIOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-253-2073
Mailing Address - Street 1:34 GREENVILLE ST
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-2602
Mailing Address - Country:US
Mailing Address - Phone:770-253-2073
Mailing Address - Fax:770-251-4202
Practice Address - Street 1:34 GREENVILLE ST
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-2602
Practice Address - Country:US
Practice Address - Phone:770-253-2073
Practice Address - Fax:770-251-4202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR001771111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00703282AMedicaid
GA00703282AMedicaid