Provider Demographics
NPI:1336228519
Name:GRAHAM, GEORGIA ROSALIE (DR OF CHIROPRACTIC)
Entity Type:Individual
Prefix:DR
First Name:GEORGIA
Middle Name:ROSALIE
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:DR OF CHIROPRACTIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 SAN PEDRO NE
Mailing Address - Street 2:#101
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-265-4697
Mailing Address - Fax:505-265-0840
Practice Address - Street 1:1330 SAN PEDRO NE
Practice Address - Street 2:SUITE 101
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-265-4697
Practice Address - Fax:505-265-0846
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM876111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
K486OtherBCBS
663252OtherACN UNITED
K486OtherBCBS