Provider Demographics
NPI:1205015195
Name:JAY GOLDKLANG DC, PC
Entity type:Organization
Organization Name:JAY GOLDKLANG DC, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDKLANG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-943-8600
Mailing Address - Street 1:4799 FAIRVILLE CT
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-6479
Mailing Address - Country:US
Mailing Address - Phone:770-943-8600
Mailing Address - Fax:770-505-2889
Practice Address - Street 1:4345 ATLANTA HWY
Practice Address - Street 2:
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-1827
Practice Address - Country:US
Practice Address - Phone:770-943-8600
Practice Address - Fax:770-505-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2008-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIRO04911111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCJSNMedicare PIN
GAU46218Medicare UPIN