Provider Demographics
NPI:1700157831
Name:VENEZIANO, VINCENT (DC)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:
Last Name:VENEZIANO
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 1:741 LYNN MILAM LN
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-4108
Mailing Address - Country:US
Mailing Address - Phone:678-602-2569
Mailing Address - Fax:770-922-9107
Practice Address - Street 1:2365 WALL ST SE
Practice Address - Street 2:SUITE 100
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30013-2197
Practice Address - Country:US
Practice Address - Phone:678-602-2569
Practice Address - Fax:770-922-9107
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-20
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5106111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00923865AMedicaid
GA00923865AMedicaid