Provider Demographics
NPI:1972722411
Name:ANTONINO, CAROL (DC, CCST)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:ANTONINO
Suffix:
Gender:F
Credentials:DC, CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 PLEASANT HILL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-6379
Mailing Address - Country:US
Mailing Address - Phone:770-623-3050
Mailing Address - Fax:
Practice Address - Street 1:4300 PLEASANT HILL RD
Practice Address - Street 2:SUITE B
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6379
Practice Address - Country:US
Practice Address - Phone:770-623-3050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA4729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCCQBMedicare ID - Type Unspecified