Provider Demographics
NPI:1811169378
Name:CENTENNIAL CHIROPRACTIC
Entity type:Organization
Organization Name:CENTENNIAL CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORIBALDI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-649-1730
Mailing Address - Street 1:4343 SHALLOWFORD RD
Mailing Address - Street 2:SUITE B6
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30062-5023
Mailing Address - Country:US
Mailing Address - Phone:770-649-1730
Mailing Address - Fax:770-649-1731
Practice Address - Street 1:4343 SHALLOWFORD RD
Practice Address - Street 2:SUITE B6
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30062-5023
Practice Address - Country:US
Practice Address - Phone:770-649-1730
Practice Address - Fax:770-649-1731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA005452261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDJRMedicare UPIN