Provider Demographics
NPI:1700166956
Name:STRUCTURAL BASED THERAPY, LLC
Entity Type:Organization
Organization Name:STRUCTURAL BASED THERAPY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ANGELO
Authorized Official - Last Name:MAIORINO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:678-469-4133
Mailing Address - Street 1:3719 OLD ALABAMA RD
Mailing Address - Street 2:SUITE 400 A
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30022-8675
Mailing Address - Country:US
Mailing Address - Phone:678-469-4133
Mailing Address - Fax:
Practice Address - Street 1:3719 OLD ALABAMA RD
Practice Address - Street 2:SUITE 400 A
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30022-8675
Practice Address - Country:US
Practice Address - Phone:678-469-4133
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-19
Last Update Date:2011-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008110111N00000X
NYX009403-1111N00000X
GAMT004280174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty