Provider Demographics
NPI:1740967603
Name:SANTIAGO MIRANDA, JEAN LUIS (DC)
Entity type:Individual
Prefix:DR
First Name:JEAN
Middle Name:LUIS
Last Name:SANTIAGO MIRANDA
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 1:2401 WINDY HILL RD SE APT 1759S
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-8525
Mailing Address - Country:US
Mailing Address - Phone:787-307-6639
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW STE 309
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7118
Practice Address - Country:US
Practice Address - Phone:404-734-6122
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010991111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor