Provider Demographics
NPI:1932239597
Name:CREATIVE CHIROPRACTIC HEALTH CLINIC
Entity Type:Organization
Organization Name:CREATIVE CHIROPRACTIC HEALTH CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:EDUARDO
Authorized Official - Last Name:BERBESSI
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:706-367-7644
Mailing Address - Street 1:1872 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-2668
Mailing Address - Country:US
Mailing Address - Phone:706-367-7644
Mailing Address - Fax:706-367-7644
Practice Address - Street 1:1872 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-2668
Practice Address - Country:US
Practice Address - Phone:706-367-7644
Practice Address - Fax:706-367-7644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005871111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGXWMedicare ID - Type UnspecifiedCHIROPRACTOR