Provider Demographics
NPI:1184789042
Name:LECROY, CHARLES D (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:D
Last Name:LECROY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 LAKE RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114-8995
Mailing Address - Country:US
Mailing Address - Phone:404-348-7250
Mailing Address - Fax:770-720-1389
Practice Address - Street 1:3542 SIXES RD
Practice Address - Street 2:STE 100
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114-9124
Practice Address - Country:US
Practice Address - Phone:770-720-1388
Practice Address - Fax:770-720-1389
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008065111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor