Provider Demographics
NPI:1700806932
Name:GRELLER, EVAN (DC)
Entity Type:Individual
Prefix:DR
First Name:EVAN
Middle Name:
Last Name:GRELLER
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 1:855 SUNSET DR
Mailing Address - Street 2:STE 8
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-7718
Mailing Address - Country:US
Mailing Address - Phone:706-543-5212
Mailing Address - Fax:706-549-1480
Practice Address - Street 1:855 SUNSET DR
Practice Address - Street 2:STE 8
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-7718
Practice Address - Country:US
Practice Address - Phone:706-543-5212
Practice Address - Fax:706-549-1480
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6000111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA582586980OtherBCBS
GAU69988Medicare UPIN
GA35ZCFFKMedicare ID - Type Unspecified