Provider Demographics
NPI:1770883985
Name:KENNESAW MOUNTAIN CLINC INC
Entity type:Organization
Organization Name:KENNESAW MOUNTAIN CLINC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:COMANOR
Authorized Official - Suffix:
Authorized Official - Credentials:DC ND
Authorized Official - Phone:770-427-0119
Mailing Address - Street 1:850 KENNESAW AVE
Mailing Address - Street 2:C-9
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060
Mailing Address - Country:US
Mailing Address - Phone:770-427-0119
Mailing Address - Fax:770-485-3018
Practice Address - Street 1:850 KENNESAW AVE
Practice Address - Street 2:C-9
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060
Practice Address - Country:US
Practice Address - Phone:770-427-0119
Practice Address - Fax:770-485-3018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004810111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCBXKMedicare PIN
GAU28356Medicare UPIN