1487842910 NPI number — FORTIN FAMILY CHIROPRACTIC AND SPORTS HEALTH, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487842910 NPI number — FORTIN FAMILY CHIROPRACTIC AND SPORTS HEALTH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FORTIN FAMILY CHIROPRACTIC AND SPORTS HEALTH, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1487842910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6000 MEDLOCK BRIDGE PKWY
Provider Second Line Business Mailing Address:
SUITE C-300
Provider Business Mailing Address City Name:
JOHNS CREEK
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30022-8172
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-476-9626
Provider Business Mailing Address Fax Number:
770-476-1310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6000 MEDLOCK BRIDGE PKWY
Provider Second Line Business Practice Location Address:
SUITE C-300
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30022-8172
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-476-9626
Provider Business Practice Location Address Fax Number:
770-476-1310
Provider Enumeration Date:
10/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FISHER
Authorized Official First Name:
PATRICIA
Authorized Official Middle Name:
P.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
770-476-9626

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  005857 , 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)





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