Provider Demographics
NPI:1245365477
Name:MOBOLADE, EDITH (DC)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:MOBOLADE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2381 SCOTNEY CASTLE LN
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-5904
Mailing Address - Country:US
Mailing Address - Phone:770-778-0088
Mailing Address - Fax:770-590-9765
Practice Address - Street 1:981 CONCORD RD SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30080-4267
Practice Address - Country:US
Practice Address - Phone:770-778-0088
Practice Address - Fax:770-319-6377
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR007498111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAV08365Medicare UPIN
GA35ZCJMWMedicare ID - Type UnspecifiedPROVIDER#