Provider Demographics
NPI:1982729380
Name:SPECIFIC CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:SPECIFIC CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BULKIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:770-513-0950
Mailing Address - Street 1:4799 SUGARLOAF PKWY
Mailing Address - Street 2:STE L
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30044-8836
Mailing Address - Country:US
Mailing Address - Phone:770-513-0950
Mailing Address - Fax:770-513-0570
Practice Address - Street 1:4799 SUGARLOAF PKWY
Practice Address - Street 2:STE L
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30044-8836
Practice Address - Country:US
Practice Address - Phone:770-513-0950
Practice Address - Fax:770-513-0570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2008-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5398111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4999Medicare PIN