Provider Demographics
NPI:1649453986
Name:TELFAIR FAMILY CHIROPRACTIC CENTER
Entity type:Organization
Organization Name:TELFAIR FAMILY CHIROPRACTIC CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:BASS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:229-868-9899
Mailing Address - Street 1:507 E OAK ST
Mailing Address - Street 2:
Mailing Address - City:MC RAE
Mailing Address - State:GA
Mailing Address - Zip Code:31055-1637
Mailing Address - Country:US
Mailing Address - Phone:229-868-9899
Mailing Address - Fax:229-868-2890
Practice Address - Street 1:507 E OAK ST
Practice Address - Street 2:
Practice Address - City:MC RAE
Practice Address - State:GA
Practice Address - Zip Code:31055-1637
Practice Address - Country:US
Practice Address - Phone:229-868-9899
Practice Address - Fax:229-868-2890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR006990111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7218OtherMEDICARE GROUP
GA35ZCJGNMedicare PIN
GAU17832Medicare UPIN