Provider Demographics
NPI:1134355779
Name:TUCKER NECK AND BACK, LLC
Entity type:Organization
Organization Name:TUCKER NECK AND BACK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TONY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BANGUILAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-621-5585
Mailing Address - Street 1:4880 LAWRENCEVILLE HWY
Mailing Address - Street 2:SUITE 13
Mailing Address - City:TUCKER
Mailing Address - State:GA
Mailing Address - Zip Code:30084-2938
Mailing Address - Country:US
Mailing Address - Phone:770-621-5585
Mailing Address - Fax:770-414-7355
Practice Address - Street 1:4880 LAWRENCEVILLE HWY
Practice Address - Street 2:SUITE 13
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-2938
Practice Address - Country:US
Practice Address - Phone:770-621-5585
Practice Address - Fax:770-414-7355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-10
Last Update Date:2009-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR0006452111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitationGroup - Multi-Specialty