Provider Demographics
NPI:1184730608
Name:FORTIN CHIROPRACTIC & ATHLETIC HEALTH CARE CENTER
Entity type:Organization
Organization Name:FORTIN CHIROPRACTIC & ATHLETIC HEALTH CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:P
Authorized Official - Last Name:FORTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-760-0060
Mailing Address - Street 1:1003 E FREEWAY DR SE
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-5927
Mailing Address - Country:US
Mailing Address - Phone:770-760-0060
Mailing Address - Fax:770-760-0409
Practice Address - Street 1:1003 E FREEWAY DR SE
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-5927
Practice Address - Country:US
Practice Address - Phone:770-760-0060
Practice Address - Fax:770-760-0409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1411111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADG7126OtherMEDICARE RAILROAD
U35977Medicare UPIN
GADG7126OtherMEDICARE RAILROAD