1356635023 NPI number — DR. NICHOLAS DWAYNE CARLISLE D.C.

Table of content: DR. NICHOLAS DWAYNE CARLISLE D.C. (NPI 1356635023)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356635023 NPI number — DR. NICHOLAS DWAYNE CARLISLE D.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLISLE
Provider First Name:
NICHOLAS
Provider Middle Name:
DWAYNE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.C.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356635023
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10945 STATE BRIDGE RD
Provider Second Line Business Mailing Address:
SUITE 401-160
Provider Business Mailing Address City Name:
ALPHARETTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30022-8164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
404-316-1190
Provider Business Mailing Address Fax Number:
404-420-2939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5009 ROSWELL RD STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ATLANTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30342-2205
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
404-264-9553
Provider Business Practice Location Address Fax Number:
404-420-2939
Provider Enumeration Date:
05/31/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CHIR008621 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)